rl pneumococcal vaccination consent form...signature: _____ to be completed by person administering...
TRANSCRIPT
![Page 1: RL Pneumococcal Vaccination Consent Form...Signature: _____ To be completed by person administering vaccine Site of Injection: I have read or had explained to me the Vaccination Information](https://reader033.vdocument.in/reader033/viewer/2022051510/5ffe095d0e6cf826a125ca6e/html5/thumbnails/1.jpg)
Resident Information
Screening for influenza vaccine eligibility
1. Have you ever had a life-threatening reaction to the pneumococcal vaccine? NoYes
Are you moderately or severely ill today? Yes No2.
vaccinate when resident has recovered. If yes to any questions 1 then DO NOT vaccinate with pneumococcal vaccine. If yes to question 2,
and I understand the benefits and risks of pneumococcal vaccination. I request that the pneumococcal vaccination be given to me (or the person named above for whom I am authorized to make this request).
Signature: ____________________________________ Date:
To be completed by person administering vaccine
Site of Injection: Administered by:R L
Last Name: First Name: Date of Birth:
Name (print or type):
Relationship to Resident:
Today's Date:
Pneumococcal Vaccination Consent Form
Lot Number: Expiration Date:
Medical Record Number: Room Number:
I have read or had explained to me the Vaccination Information Statement about pneumococcal vaccination
Age of Patient: