Respiratory Syncytial Virus (RSV) 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 respiratory syncytial virus (RSV) vaccine. If you answer “NO” to all of the following questions, you can get the respiratory syncytial virus (RSV) vaccine. If you answer “YES” to one or more of the following questions, you may not be able to get the respiratory syncytial virus (RSV) vaccine.
Please mark YES or NO for each question. | YES | NO |
1. Do you have serious allergies to any component of the RSV vaccine? | | |
2. Do you have any other serious allergies? | | |
Section 3: Consent
CONSENT FOR VACCINATION:
I have read or had explained to me the 20____ - 20____ Vaccine Information Statement for the respiratory syncytial virus (RSV) vaccine and understand the risks and benefits, and recommendations as per current CDC guidance.
I, ______________________________(resident or representative) GIVE CONSENT for ________________________________(resident’s name) to receive the RSV vaccine.
I, ______________________________(resident or representative) DO NOT GIVE CONSENT for ________________________________(resident’s name) to receive the RSV vaccine due to ________________________________________________________________________.
Signature: _______________________________________________ Date: ________________
(Resident or Resident Representative)