RUTGERS UNIVERSITY
Occupational Health Department
11 Bishop Place ·  New Brunswick  ·  New Jersey  08901-1180
Office: 848-932-8254   ·  Fax:  732-932-7199
                       
2017-2018 INFLUENZA IMMUNIZATION CONSENT FORM

Please Print

Name: _____________________________________________   Date of Birth: ________________      

Department Address: ____________________________________________________________

Phone # (either department or personal):  ____________________________________________

Department: ______________________________           Campus: _______________________



To the best of my knowledge, I do NOT have any of the following:

I have been given a copy and have read the information in the Vaccine Information Statement (VIS) about the inactivated influenza vaccine dated 08/07/2015.  I have had sufficient opportunity to ask questions which have been answered to my satisfaction. I understand the benefits and risks of the influenza vaccine and I request that I be immunized with this vaccine.

 

I UNDERSTAND THAT IF I HAVE ANY COMPLICATIONS FROM THE INFLUENZA VACCINE, I MUST SEEK CARE FROM MY PRIVATE PHYSICAN.

 

Signature: _______________________________                                     Date: _____________

Occupational Health collaborates with Rutgers researchers to find ways to increase the number of persons who are vaccinated against the flu. De-identified vaccination information at Rutgers may be studied for that purpose. If you wish to receive the vaccine but do not wish your vaccination record to be included in the study, please notify Occupational Health Department Nurse at the time you obtain your flu shot.

 

 

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FOR CLINIC USE: 08/18/16 updated

Vaccine

Date

Lot#

Manufacturer

ExpDate

Site

Route

Dose

Initials

Influenza

 

XN54L

GSK

06/07/18

LD/RD

IM

0.5ml

JOB/MD/SC/MG