Consent Forms For Influenza and Pneumococcal Vaccines And Tetanus-Diphtheria Toxoids

Please discuss any questions you may have, or request for more information, with the nurse or the attending physician.

INFLUENZA VACCINE: The influenza vaccine has been shown to protect older adults from hospitalization and deaths, resulting from an influenza infection. The Advisory Committee on Immunization Practices (ACIP) recommends that influenza vaccine be provided to all residents of nursing facilities, annually, prior to the influenza season. Reactions at the site of injection may occur. Mild fever or aches may also occur. This facility usually conducts an organized vaccine campaign between October and mid-November, before the beginning of the influenza season. However, influenza vaccine will be offered to residents and to new arrivals through the end of January of the subsequent year.

 

INFLUENZA VACCINE:

____ YES - I wish to receive the influenza vaccine on an annual basis while I am residing in this facility.

____ NO - I do not wish to receive the influenza vaccine this year.

Resident’s Name:________________________________

Resident or Responsible Party’s Signature ____________

Date: ____________

 

PNEUMOCOCCAL VACCINE: The Pneumococcal Polysaccharide Vaccine is effective against 23 pneumococcal types which cause 90 percent of all pneumococcal pneumonia and is effective for approximately six (6) years. Anyone 65 years of age or older or having chronic health problems is considered high risk for exposure to and complications from pneumococcal infections such as pneumonia, septicemia, and meningitis. The ACIP currently recommends a single dose of the vaccine for persons 65 years and older who have not been previously vaccinated or whose vaccination status is unknown. A one-time revaccination is recommended for persons 65 years and older who have been vaccinated for the first time when they were 60 years of age or younger. Local site reactions are expected in 5-10% of vaccine recipients. Less than 1% of vaccinees have reported slight elevations of body temperature but severe allergic reactions reactions have not been documented.

 

PNEUMOCOCCAL VACCINE:

___ YES - I wish to receive pneumococcal vaccine according to the recommended schedule.

___ NO - I do not wish to receive the pneumococcal vaccine at this time.  (This vaccine will be offered again at a later time.)

Resident’s Name:_______________________________

Resident or Responsible Party’s Signature: ___________

Date:  ___________

TETANUS & DIPHTHERIA TOXOIDS: The ACIP recommends that the combined Td toxoid be administered at 10 year intervals to reduce the risk of tetanus or respiratory diphtheria among older adults. Td may be administered simultaneously with other vaccines. Reactions at the site of injection may occur. Persons who had extreme localized reactions, or other adverse effects, to Td toxoid in the past should indicate to the nursing staff, or the Medical Director, the exact nature of the reaction and the number of years that have passed since the reaction occurred.

Td:

___ YES - I wish to receive the Td toxoid according to the recommended schedule.

___ NO - I do not wish to receive the Td toxoid at this time.

Resident’s Name:________________________________

Resident or Responsible Party’s Signature:____________

Date:____________