Influenza Immunization Informed Consent

Resident:

Room:

Check the appropriate box:

I hereby give Daughters of Israel permission to administer an influenza vaccination annually, in the fall. To the best of my knowledge, I have not had an allergic reaction or anaphylactic* reaction to eggs, a sensitivity to thimerosal or allergy to sodium bisulfate.

I have been instructed that as a result of this vaccination, I may experience some side effects such as:
     Slight discomfort;
     Soreness of the arm;
     Redness of the arm;
     Slight fever (occasionally); and
     Muscle aches (occasionally.

To the best of my knowledge, I have had an allergic reaction or anaphylactic* reaction from the influenza vaccination in the past and therefore decline to have this vaccine administered.

Signature of Resident

Date

I, , the Responsible Representative for , who is my , and a resident of this facility, hereby give my permission for the facility to administer an influenza vaccination annually, in the fall. To the best of my knowledge, has not had an allergic reaction or anaphylactic* reaction to eggs, a sensitivity to thimerosal or allergy to sodium bisulfate.

To the best of my knowledge, has had an allergic reaction or anaphylactic* reaction from the influenza vaccination in the past and therefore decline to have this vaccine administered.

Signature of Responsible Representative	Date
Signature/Title of Witness	Date

* An anaphylactic reaction is a severe drug induced reaction causing such symptoms as severe difficulty in breathing, fainting, shock, sever hives or patches of fluid under the skin, and intense itching. It can be a life threatening response to a drug.

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Phone: 973-731-5100 • Fax: 973-736-7698
www.doigc.org
1155 Pleasant Valley Way, West Orange, NJ, 07052