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Influenza Vaccination Standing Orders Influenza Vaccination Standing Orders

Influenza Vaccination Standing Orders - PowerPoint Presentation

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Uploaded On 2016-05-13

Influenza Vaccination Standing Orders - PPT Presentation

Page 1 of 1 required for saving conditionally required Facility ID DO NOT VACCINATE Check one Imprint patient information or place patient label here Patient is less than 6 months old ID: 317579

influenza vaccine check patient vaccine influenza patient check seasonal administered information vis required vaccinate individual declined vaccinated reason apply date institution fluzone

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Slide1

Influenza Vaccination Standing Orders

Page 1 of 1

* required for saving

^ conditionally required

*Facility ID:

DO NOT VACCINATE (Check one)

(*Imprint patient information or place patient label here)

Patient is less than 6 months old.

Patient has been previously vaccinated.

*

Vaccine offered:

Yes

No

^Influenza

Subtype:

Seasonal

Non-seasonal

*Vaccine declined:

Yes

No

Reason(s) vaccine declined (Check either section A or B but not both)

A. Medical contraindication(s)

(check all that apply)

:

B. Personal reason(s) for declining

(check all that apply)

:

Previously vaccinated this season

Allergy to vaccine components

History of

Guillian-Barre

syndrome within 6 weeks of previous influenza vaccination

Current febrile illness (Temp > 101.5°F)

Other (specify): ____________________________________

Fear of needles/injections

Fear of side effects

Perceived ineffectiveness of vaccine

Religious or philosophical objections

Concern for transmitting vaccine virus to contacts

Other (specify):_______________________

__________________________________

*Orders:

Vaccinate

Do NOT vaccinate

Standing Order – no signature required

^Physician Signature:

*Vaccine administered:

Yes

No

^Date Administered:

^Type of influenza vaccine administered:

Seasonal:

Afluria

®

Agriflu

®

Fluarix

®

FluLaval

®

Flumist

®

Fluvirin

®

Fluzone

®

Fluzone

High-Dose

®

Other (specify) ___________________________

Non-seasonal:

Other (specify) _____________________________

Live attenuated influenza vaccine (LAIV) e.g., nasal

Inactivated vaccine (TIV)

^Manufacturer: _____________________________ ^Lot number: _______________________

^Route of administration:

Intramuscular

Intranasal

Subcutaneous

Vaccine Information Statement (VIS) Provided to Patient:

Live Attenuated Influenza VIS

Inactivated Influenza VIS

None

Unknown

Edition Date: ________/_________/________

Vaccinator ID of

Person Administering Vaccine

: Title:

Name: Last: First: Middle:

Work Address: _________________________________________________________________________

City:_____________________________ State: _________________________ Zip code: _____________

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).