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201617 School Based Influenza Vaccine Consent Form
BRANTLEY COUNTY HEALTH DEPARTMENT
Section 1: Information About the Student Who Will Receive Influenza Vaccine (please print)
MIDDLE INITIALSTUDENTS
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Ethnicity refers to a person's identification with a particular group based on cultural, national, tribal, religious, or other affiliations.
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The purpose of collecting ethnicity data is to understand the diversity and demographics of a population for statistical analysis, representation, and equal opportunity purposes.
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The information reported on ethnicity typically includes categories such as Hispanic or Latino, American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White.
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