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CENTER FOR CORPORATE WELLNESS
SEASONAL FLU VACCINE PROGRAM
20192020 CONSENT AND RELEASE FORM
I have read the information contained in the CDC Influenza Vaccine Information Sheet (see attached) and
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How to fill out vaccine information statementinactivated influenza

How to fill out vaccine information statementinactivated influenza
01
Obtain a copy of the vaccine information statement for inactivated influenza.
02
Read the statement carefully to understand the information it provides.
03
Gather all the necessary information about the vaccine, such as the manufacturer's name, lot number, and expiration date.
04
Fill out the patient's personal information section on the statement, including their name, date of birth, and contact information.
05
Enter the healthcare provider's information, including their name, address, and contact details.
06
Provide information about the date the vaccine was administered and the site of administration.
07
Record the vaccine's lot number, manufacturer's name, and expiration date.
08
Check any relevant boxes or provide additional information as required by the form.
09
Review the completed form for accuracy and make any necessary corrections.
10
Keep a copy of the filled-out vaccine information statement for your records and provide a copy to the patient or their representative.
Who needs vaccine information statementinactivated influenza?
01
Anyone who is planning to receive the inactivated influenza vaccine should read and receive the vaccine information statement. This includes individuals of all ages, from children to adults.
02
Healthcare providers who administer the inactivated influenza vaccine should also be familiar with and provide the vaccine information statement to their patients.
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What is vaccine information statementinactivated influenza?
Vaccine information statementinactivated influenza provides details about the inactivated influenza vaccine, including its benefits, risks, and possible side effects.
Who is required to file vaccine information statementinactivated influenza?
Healthcare providers administering the inactivated influenza vaccine are required to provide patients with the vaccine information statement.
How to fill out vaccine information statementinactivated influenza?
Healthcare providers can fill out the vaccine information statementinactivated influenza by hand or by using electronic systems provided by the CDC.
What is the purpose of vaccine information statementinactivated influenza?
The purpose of the vaccine information statementinactivated influenza is to inform patients about the inactivated influenza vaccine and help them make informed decisions.
What information must be reported on vaccine information statementinactivated influenza?
The vaccine information statementinactivated influenza must include details about the vaccine, its administration, possible side effects, and how to report any adverse reactions.
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