Mmf 035 - influenza vaccination questionnaire and consent

Influenza Vaccination Questionnaire and
Consent
Address:
Postcode:
Date of Birth:
Contact Phone Number:
Do you identify yourself as being Aboriginal / Torres Strait Islander Organisation / Employer: (If Applicable)
Background
Influenza viruses can cause major epidemics of respiratory disease. The illness can vary in severity and secondary complications can be significant. Symptoms include the abrupt onset of fever, pain in the muscles, sore throat, non-productive cough, headache and tiredness which may persist for several weeks and often results in restriction of activity. Adverse Events and Precautions
 The influenza vaccine is generally well tolerated  Occasional discomfort, redness and swelling at the injection site is the most common adverse reaction  Fever, muscle pain and generally feeling unwell occur infrequently within a few hours of vaccination and  Immediate adverse events such as hives, angio-oedema, asthma or systemic anaphylaxis are a rare  Guillain-Barre syndrome is rarely associated with influenza vaccination (1 in 2 million), although a direct  You are advised to remain in the observation area for a minimum of 15 minutes. Do not operate any machinery or vehicle for 30 minutes post vaccination. Current Health Status / Suitability
Before receiving influenza vaccine, please answer the following questions. The information you provide is private and confidential and will not be used for any other purpose. 1. Do you have an acute feverish illness at present?
2. Have you previously been vaccinated against Influenza?
3. Did you experience any significant problems after vaccination?
4. Have you previously had Guillian - Barre Syndrome?
5. Are you allergic to eggs or chicken feathers?
6. Are you allergic to Neomycin, Polymixin or Gentamicin?
7. Are you allergic to Formaldehyde or Thiomersal?
Are you taking any cortisone, steroid, immunosuppressive medication or theophylline, warfarin or Dilantin? (If yes, please circle which one) 9. Are you over 18?
Reference: State Manager - Community Health
Original Date: October 2008
Reviewed Date: March 2012
Influenza Vaccination Questionnaire and
Consent
Privacy Statement
Ozcare (we, us or our) is committed to the National Privacy Principles contained in the Privacy Act 1988 (Cth). The purpose of this statement is to advise you that we may collect, use and disclose various personal information about you (that is, information that can identify you) for the purposes of providing services to you, facilitating our internal business operations, including the fulfilment of any legal and regulatory requirements and providing you with information about us and the services that we offer We may disclose personal information about you to your nominated next of kin in an emergency involving you, our related entities and affiliated organisations and service providers, who assist us in operating our business If the personal information you provide to us is incomplete or inaccurate, we may be unable to provide you with the services you are seeking. Also, if we provide you with in-home care, we may leave your record of treatment with Ozcare, which includes personal information, at your home. You acknowledge that you will keep the record safe and secure and that you will inform us if any event or threatened event jeopardises the safety and security of this record You may access the personal information we hold about you in accordance with our privacy policy If you wish to access any personal information you will need to put your request in writing to: Ozcare, Privacy Officer, PO Box 912, FORTITUDE VALLEY QLD 4006 I have read and understand this information and consent to receiving an Influenza Vaccine injection Signature:
OFFICE USE ONLY
Influenza Vaccine given by:
Batch Number:
Date Given:
Vaccine Expiry Date:
Has the Client read the Privacy Statement or Has the Privacy Statement been read to the Client / Reference: State Manager - Community Health
Original Date: October 2008
Reviewed Date: March 2012

Source: http://immunisations.ozcare.org.au/Downloads/MMF%20035%20-%20Influenza%20Vaccination%20Questionnaire%20and%20Consent.pdf