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APPENDIX C
SCREENING QUESTIONNAIRE FOR
INACTIVATED INJECTABLE INFLUENZA VACCINATION
The following questions shall be used to determine if there is any reason an inactivated injectable
influenza vaccination should not be given:
(1) Is the person to be vaccinated under the age of 18 years?
(2) Is the person to be vaccinated sick today?
(3) Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?
(4) Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
(5) Has the person to be vaccinated ever had Guillain-Barré syndrome?
If a person answers “ yes” to any of these questions, the pharmacist must comply with Section VI
of this Protocol.
APPENDIX D
SCREENING QUESTIONNAIRE FOR LIVE
ATTENUATED INTRANASAL INFLUENZA VACCINATION
The following questions shall be used to determine if there is any reason a live attenuated intranasal
influenza vaccine should not be given:
(1) Is the person to be vaccinated sick today?
(2) Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine?
(3) Has the person to be vaccinated ever had a serious reaction to intranasal influenza vaccine (FluMist)
in the past?
(4) Is the person to be vaccinated younger than age 18 years or older than age 49 years?
(5) Does the person to be vaccinated have a long-term health problem with heart disease, lung disease,
asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g.,
diabetes), or anemia or another blood disorder?
(7) Does the person to be vaccinated have a weakened immune system because of HIV/AIDS or another
disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or
cancer treatment with radiation or drugs?
(8) Is the person to be vaccinated receiving antiviral medications?
(9) Is the person to be vaccinated pregnant or could she become pregnant within the next month?
(10) Has the person to be vaccinated ever had Guillain-Barré syndrome?
(11) Does the person to be vaccinated live with or expect to have close contact with a person whose
immune system is severely compromised and who must be in protective isolation (e.g., an isolation room
of a bone marrow transplant unit)?
(12) Has the person to be vaccinated received any other vaccinations in the past 4 weeks?
If a person answers “ yes” to any of these questions, the pharmacist must comply with Section VI of this
Protocol.
APPENDIX E
CONSENT FOR INFLUENZA VACCINE
I have read, or had explained to me, the Vaccine Information Statement for influenza vaccine. I
understand the risks and benefits, and have been provided an opportunity to ask questions, and they have
been answered to my satisfaction. I wish to receive the influenza vaccine and hereby give consent for
[Pharmacist's Name] to administer the influenza vaccine and communicate the administration of the
vaccine to my primary care practitioner, who is listed below.
_______________________________________
Vaccine recipient's name
_______________________________________
Vaccine recipient’s date of birth
______________________________________
Recipient's (or legal representative's) signature
_________________
Date
_________________
VIS Date
_____________________________________________
Vaccine recipient’s designated primary care practitioner
APPENDIX F
NOTIFICATION LETTER
Dear Healthcare Provider at [vaccinee's primary care clinic]:
We have recently provided vaccination services to one of your patients. A personal immunization record
card was filled out and given to the patient. We want to make certain that you also have this information
so that you can update your patient's medical record. Please contact us if you have any questions about
this information.
Vaccinee's name: ____________________________________
Vaccinee's Date of Birth: ____________
The vaccine that was given on _________________ is checked below.
____ Trivalent influenza vaccine (TIV)
____ Live attenuated influenza vaccine (LAIV)
Administering Pharmacist
Contact Information for Administering Pharmacist