Check the appropriate box:

I hereby give Daughters of Israel permission to administer a pneumococcal vaccination.  I understand that this immunization is usually given only once.  To the best of my knowledge, I have not received a pneumococcal vaccination (a second dose is recommended if prior status is not known). If I received it before age 65 and it was more than 5 years ago, I elect to receive it again as per federal recommendations.

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

 To the best of my knowledge, I have had a pneumococcal after the age of 65 and therefore decline to have this vaccine administered. If I had it before age 65, it was less than 5 years ago.

 I, , the Responsible Representative for , who is my , and a resident of this facility, hereby give my permission for the facility to administer a one (1) time pneumococcal vaccination.  To the best of my knowledge, has not received a pneumococcal vaccination (or received it before age 65 and it was more than 5 years ago).

 To the best of my knowledge, has had a pneumococcal vaccination in the past (or received before age 65 and was less than 5 years ago) and therefore declines to have this vaccine administered.