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Vaccination consent form for people receiving Inactivated Influenza Vaccine (IIV)


IIV (Trivalent) - Vaxgrip or Influvac Sub-unit

You can complete this form at the pharmacy on the day of your appointment, but why not save time? Fill it out online beforehand

Date of Birth
Day
Month
Year

 Please answer the following questions about the person being offered vaccination with a yes or no answer

1. Has this person ever had anaphylaxis (severe allergic reaction) following a previous dose of influenza vaccine or any of its constituents?
Yes
No

If yes, ineligible for vaccination as anaphylaxis following a previous dose of influenza vaccine or any of its constituents is a contraindication to vaccination. If no, go to next question

2a. Has this person ever required admission to ICU for a previous severe anaphylaxis to egg?
Yes
No

If yes, those requiring inactivated influenza vaccine who have had a previous ICU admission for a severe anaphylaxis to egg need to be referred for specialist assessment with regard to vaccine administration in hospital. If yes, go to question 2b. if no, go to question 3.

2b. Has this person had a specialist assessment regarding their severe egg allergy in the past requiring ICU admission and are now recommended the inactivated influenza vaccine?
Yes
No

If yes, go to next question. If no, they cannot be vaccinated today.

3. Is this person suffering from an acute febrile illness?
Yes
No

If yes, they cannot get this vaccine today, defer vaccination until recovery. If no, go to next question.

4. Is this person on combination checkpoint inhibitors such as ipilimumab or nivolumab?
Yes
No

If yes, they may not be able to have the vaccine. They may not be able to receive any flu vaccines, because of a potential association with immune related adverse reactions. This should be discussed with their treating specialist. If no, go to next question

5. Does this person have severe neutropenia (low levels of a type of white blood cell) i.e. absolute neutrophil count <0.5 × 109/L.? This does not apply to those with primary autoimmune neutropenia.
Yes
No

If yes, they should not receive the influenza vaccine, to avoid an acute vaccine related febrile episode. They are ineligible for vaccination. If no, go to next question.

6a. Is this the first time this person is receiving the influenza vaccine this season (September to April)?
Yes
No

f yes, go to Question 7. If no, please answer question 6b.

6bVery few people need a second dose of influenza vaccine. Does the person receiving the vaccine fit any of the criteria:
Yes
No

 If yes, they can receive a second influenza vaccine this season, at least 4 weeks since their first dose (and at least 4 weeks after completion of treatment for patients completing cancer treatment). If no, they do not require a second influenza vaccine.

7. Does this person have any illness or condition that increases their risk of bleeding?
Yes
No

If yes, Individuals with a bleeding disorder or receiving anticoagulant therapy may develop haematomas in intramuscular (IM) injection sites. Prior to vaccination, inform the recipient about this risk. For those with thrombocytopenia (platelet count <50x10³), consult the supervising consultant. Proceed if fits clinical criteria. If no, go to question 8.

8. Is this person a child aged 12-23 months who has received a PCV vaccine within the last week?
Yes
No

If yes, then defer flu vaccine by at least one week from the PCV vaccine, if no, vaccination may proceed today.

Consent: I have read and understood the influenza vaccination leaflet and have been given an opportunity to speak to the pharmacist providing the vaccine. I understand:

  • The nature of the treatment.

  • The benefits and risks of immunisation.

  • The risks of influenza.

  • The possible side effects of vaccination, when they might occur and how they should be treated.

I have been given an opportunity to ask questions and raise any concerns.

I agree that the details I have supplied have been recorded and those records will be kept by Coombe Communitpharmacy and shared with the HSE for the purposes of public health as required by legislation.

VACINATION CONSENT
1. The individual has consented to vaccination with influenza vaccine and has been provided with written information, OR
2. The individual does not consent to influenza vaccination and should not be vaccinated, OR
3. The individual cannot consent and they are being vaccinated with Influenza vaccine according to their benefit and will and preference, AND

AND The above is recorded in their healthcare record and includes information about any consultation that has taken place to help determine their will and preference.

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