Pneumococcal-Vaccine-Consent-Form

Pneumococcal Vaccine Consent Form

Section 1: Information about person to receive vaccine (please print)

NAME (Last)

(First)

(M.I.)

DATE OF BIRTH

month_________ day_____ year _______

Section 2: Screening for Vaccine Eligibility

The following questions will help us to know if you can get the Pneumococcal vaccine. If you answer “NO” to all four of the following questions, you can get this vaccine. If you answer “YES” to one or more of the following four questions, you may not be able to get this vaccine.

Please mark YES or NO for each question.	YES	NO
1. Do you have a moderate or severe acute illness with or without fever?	⁭	⁭
2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) after a dose of this vaccine?	⁭	⁭
3. Have you ever had a life-threatening reaction to any type of pneumococcal conjugate vaccine (PCV) (PCV13, PCV15, PCV20 or PCV7)?	⁭	⁭
4. Have you ever had a life-threatening reaction to any vaccine containing diphtheria toxoid (for example, DTaP)?	⁭	⁭

Section 3: Consent

CONSENT FOR VACCINATION:

I have read or had explained to me the 20____ - 20____ Vaccine Information Statement for the Pneumococcal vaccine and understand the risks and benefits.

⁭ I, _______________________________ (resident or representative) GIVE CONSENT for _________________________________ (resident’s name) to receive the pneumococcal vaccine.

⁭ I, ______________________________ (resident or representative) DO NOT GIVE CONSENT for ______________________________ (resident’s name) to receive the pneumococcal vaccine due to ______________________________________________________________________.

Signature: _______________________________________________ Date: ____________________

(Resident or Resident Representative)