1. Healthcare

Child’s Name: __________________________________________
Teacher/Grade/Classroom#: ______________________________
The Oklahoma Caring Van is offering free flu vaccine to children who qualify for the Vaccines for
Children (VFC) Program.
In order for your child to qualify for the VFC program,
one of the following criteria must be satisfied.
Please check all of the following that apply. (At least one box must be checked to receive vaccine):
□ My child is covered through Soonercare/Medicaid #____________
□ My child is Native American.
□ My child is Native Alaskan, Native Hawaiian or other Pacific Islander.
□ My child does not have private insurance.
If you checked any of the items above, please mark your preference below:
□ I would like my child to receive the flu injection only.
□ I would like my child to receive the flu mist only.
□ My child may have the flu injection or flu mist, whichever is available.
Screening Questions for Inactivated (Shot) Flu Vaccine
1. Has your child ever had an influenza vaccine?
2. Has your child ever had a bad reaction to the influenza vaccine?
If “yes” what was the reaction?__________________
3. Does your child have a fever, infection or current illness today?
If “yes” what illness? __________________________
4. Is your child allergic to chicken eggs, latex, thimerosal or gelatin?
If “yes” what kind of reaction? __________________
5. Has your child experienced Guillain-Barre syndrome?
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Screening Questions for Live Nasal (mist) Influenza Vaccine
Note: If your child has had wheezing or asthma in the last year nasal mist can NOT be given
1. Is your child pregnant?
Yes No
2. Is the patient between 2 and 4 years of age and has wheezing or asthma?
Yes No
3. Does your child have long term health problems with heart, lung, kidney, etc.?
Yes No
4. Is the patient a child or adolescent on long-term aspirin treatment?
Yes No
5. Has your child had one or more episodes of wheezing in the past year?
Yes No
6. Does your child have allergic reaction to egg, arginine, gentamicin, and/or gelatin? Yes
No
If “yes” describe __________________________
7. Is your child currently taking antiviral medication or have taken in the last 48 hours? Yes No
If “yes” what medication _____________________
8. Has the person to be vaccinated received any other vaccinations in the past 4 weeks? Yes No
If “yes” what vaccinations?_____________________
9. Does your child have a weakened immune system or do you live with
anyone who does?
Yes No
If “yes what___________ Do they live in the home with you? ________
OKLAHOMA
CARING VAN
PROGRAM
Flu Immunization Authorization Form
Complete front and back with your child's information.
NAME OF CHILD CARE FACILITY OR EVENT / NOMBRE DE LA GUARDERIA Ó EVENTO INFANTIL
DATE / FECHA
LAST NAME / APELLIDO PATERNO
NOMBRE
FIRST / NOMBRE
ADDRESS / DIRECCIÓN
CITY /
CIUDAD
BIRTHDATE (MM/DD/YY) / FECHA DE
NACIMIENTO
AGE / EDAD
MIDDLE INITIAL / SEGUNDO
STATE /
ESTADO
SOCIAL SECURITY NUMBER / NUMERO DE
SEGURO SOCIAL
ZIP CODE / CÓDIGO POSTAL
PHONE / TELÉFONO
(
SEX / SEXO
M
BIRTH STATE / ESTADO DE NACIMIENTO
)
MOTHER'S MAIDEN NAME / MADRES
APELLIDO DE SOLTERA NOMBRE
F
RACE / RAZA
 BLACK / NEGRA
 WHITE / BLANCA
 AMERICAN INDIAN / NATIVA AMERICANA
 ASIAN / ASIÁTICA
 PACIFIC ISLANDER / ISLA DEL
PACIFICO
 OTHER / OTRA
 ALASKA NATIVE / NATIVA DE ALASKA
 WHITE HISPANIC / HISPÁNICA BLANCA
I consent and understand that the below marked immunization will be delivered by the Tulsa-City-County Health Department with assistance from the
Oklahoma Caring Vans Program. I have read or had explained to me the information contained in the Vaccine Information Statement(s) about the
disease(s) and the vaccine(s). I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the
vaccine(s) and request that the vaccine(s) be given to me or the person for whom I am authorized to make this request. I have reviewed the Notice of
Health Information Practices and understand that immunization and billing information may be provided to school/child care officials, public health officials,
health care professionals and insurance processing entities. (A copy of the Notice of Health Information Practices will be provided upon request.)
This consent shall remain in effect for 90 days after the
date signed.
Please check one of the following boxes:
My child's immunizations can be done without my presence.

My child's immunizations can only be done with my presence.

Yo estoy de acuerdo y entiendo que la vacuna marcadas abajo serán distribuidas por el Departamento de Salud con la asistencia de Oklahoma Caring
Van Programs. Yo he leido o se me ha explicado la información contenida en el informe Sobre la Vacuna acerca de la(s) enfemidad(es) y la(s) vacunas.
Yo he tenido la oportunidad de hacer preguntas las cuales feuron contestadas a mi satisfacción. Yo entiendo los beneficios y los riesgos de la(s)
vacuna(s)_y pido que dichas vacunas se me administren a mi o a la persona para quien estoy autorizado/a a hacer esta petición. Yo he revisado el
informativo Prácticas Sobre Información Médica, y entiendo que la información sobre vacunaciones y cobro, peude ser proporcionada a oficiales de
escuela/guarderias infantiles, oficiales profesionales de la salud pública, y entidades de preceso de compañias de seguros. (Se puede obtener una copia
del Informativo Prácticas Sobra información Médica si se lo solicita)
Este consentimiento permanecerá en efecto por 90 dias a partir de la fecha en que
se firmó.
POR FAVOR MARQUE UNA DE LAS SIGUIENTES
OPCIONES
Mi niño puede recibir las vacunas sin mi presencia

Mi niño puede recibir las vacunas solamente con mi presencia

SIGNATURE OF PARENT OR LEGAL GUARDIAN / FIRMA DEL PADRE O
GUARDIÁN LEGAL
DATE /
FECHA
RELATIONSHIP TO CHILD /
RELACIÓN

Below for nurse
use only.
Vaccine Name
Lot
Site
□ Flu Injection
□ Nasal Mist
□ Other:
SIGNATURE OF NURSE
DATE
All immunizations are offered at no charge. Todas las vacunas se ofrecen de forma gratuita.
Please return the completed form to the school by
________________________________________.