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Fast Track H1N1 Vaccine Consent Form

Description:

This 2-page consent form was used for a fast track H1N1 only clinic outside Knox County Health Department's usual clinic location. The form collects standard personal information and medical history from the patient. On the second page, the health care provider submits vaccine and site administration data.

This tool was submitted as part of an H1N1 Story from the Field. The story can be found at this link:  http://www.naccho.org/topics/H1N1/h1n1story.cfm?story_id=293

    

Toolkit:

Influenza Toolkit

Keyword Area:

Immunization, Pandemic Influenza

Jurisdiction:

Institutional Author:

Knox County Health Department

Submitted:

02/03/2010

Modified:

02/23/2010

The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.