WRHA Influenza and Pneumococcal Vaccine Consent Form

Influenza and Pneumococcal Immunization Consent Form/
Formulaire de consentment à la vaccination antigrippale et antipneumococcique
Surname / Nom de famille
Given Name / Prénom
Address / Adresse
Home Phone / Téléphone à domicile
Date of Birth (year/month/day)
Date de naissance (année/mois/jour)
/
/
Gender / Sexe
Male / Masc.
Female / fém
o
Manitoba Family Registration Number (MFRN) (6 digits) / N d’immatriculation familial de Santé Manitoba (NIFM) (6 chiffres)
o
Personal Health Information Number (PHIN) (9 digits) / N d’identification médical personnel (NIMP) (9 chiffres)
Completed by: /
Complété par:
Self / Soi-même
Health Care Provider (completing on behalf of person being immunized) /
Fournisseur de soins (complété pour la personne qui reçoit la vaccination)
Parent/Legal Decision Maker (completing on behalf of person being immunized) /
Parent/décideur légal (complété pour la personne qui reçoit la vaccination)
1. Are you well today? / Vous sentez-vous bien aujourd’hui? Yes / Oui
No / Non
If no, describe / Si non, décrivez
2. Do you have any allergies? / Souffrez-vous d’allergies?
Yes / Oui
No / Non
If yes, describe / Si oui, lesquelles
3. Do you have any conditions that require regular visits to the doctor? /
Êtes-vous atteint d’une affection qui exige des rendez-vous périodiques chez le medecin?
Yes / Oui
No / Non
If yes, describe / Si oui, décrivez
4. Are you taking any medications? / Prenez-vous des médicaments?
Yes / Oui
No / Non
If yes, describe / Si oui, décrivez
5. Have you had a serious reaction or condition occur following an immunization (influenza or other)? / Avez-vous eu des
réactions ou conditions graves lors de vaccinations antérieures (vaccin antigrippal ou autres)?
Yes / Oui
No / Non
If yes, describe / Si oui, décrivez
6. Are you pregnant? / Êtes-vous enceinte?
Yes / Oui
No / Non
“I have read and understand the information provided. Based on this information: YES, I do consent to the above
named person receiving the vaccine identified below.”
« J’ai lu et compris les renseignements fournis et d’après ces renseignements, OUI, je donne mon accord à ce que la
personne dont le nom figure sur ce formulaire reçoive le vaccin ci-dessous. »
Check off and sign for each vaccine that you are consenting to be administered to the person. / Cochez et signez pour tous les
vaccins auxquels vous donnez votre consentement.
Influenza vaccine / Vaccin antigrippal
Signature
Date
Pneumococcal vaccine / Vaccin antipneumococcique
Date
Name / Nom
Contact Numbers / Tél. Home / Dom
Relationship / Lien de parenté ou autre
Work / Trav
FOR WRHA HEALTH CARE WORKERS ONLY: Complete check box on reverse of this page
W-00231
Cell
Clinic date:
Clinic Location:
For Immunization Provider Use only
Influenza Vaccine
Reason for Immunization (check one only)
Health Care Worker
High Risk Chronic
Household Contact (or volunteer)
Informed consent provided by client
Nurse’s Initials
Informed consent provided by parent or legal decision maker (see pg. 1)
Nurse’s Initials
No Risk *
*This category only to be used when individual not eligible for publicly funded vaccine
Date Y/M/D
Vaccine
Lot #
Manufacturer
Dose
Route
Penumococcal Vaccine
Immunization records checked. No record of previous dose
Informed consent provided by client
Informed consent provided by parent or legal decision maker (see pg. 1)
Date Y/M/D
Vaccine
Lot #
Manufacturer
Dose
Route
Site
Administered by (nurse’s
signature)
Initials
Nurse’s Initials
Nurse’s Initials
Site
Administered by (nurse’s
signature)
For Occupational Health Purposes Only
Completed for WRHA Health Care Workers Only
I am employed by (please check appropriate boxes):
Community Health
Health Care Facilities
Services
Home Care
Concordia Hospital
Mental Health
Deer Lodge Centre
Primary Care
Public Health
Grace General Hospital
Health Sciences Centre
Site address:
Misericordia Health
Centre
Pan Am Clinic
Riverview Health Centre
SOGH
St. Amant
St. Boniface Hospital
Victoria General Hospital
Personal Care Home
Name of PCH:
Program/Department
September 2008
WRHA Operations
Other
Laundry Operations
Logistics Services
Cancer Care Manitoba
FSH
RDF
Seven Oaks Wellness
Institute
Tissue Bank
Physician
Student
WRHA Corporate
WRHA Other (specify)
Volunteer
Other (specify)
University of Manitoba