SBHC Flu Vaccine (rev 20210721) SBHC flu vaccine 20210721 Get your Flu Vaccine at the Child & Family Agency SBHC! The 2021-2022 Influenza Vaccine is now available online for all students seen at the School Based Health Center (SBHC). Students must be enrolled in the SBHC in order to get the flu vaccine or any medical care. For any questions, please call the Child & Family Agency SBHC program office: 860-437-4550. Is your child in elementary school or high school?* Elementary school Middle/High school Child's Name* First Last Date of Birth* MM slash DD slash YYYY School* Grade* Homeroom* Parent/Guardian Name* First Last Parent/Guardian Phone*Pediatrician Name* Pediatrician Phone*Vaccine Consent* I want the SBHC nurse practitioner to give my child the flu vaccine. I will have my child’s health care provider’s office administer the flu vaccine. I do not want my child to receive the flu vaccine this year. I would like my child to receive:* the injectable/shot (inactivated) flu vaccine the nasal spray (live) flu vaccine I want to be present*If you would like to be present for your child’s vaccine, please call 860-437-4550 to set an appointment. Otherwise, a time will be set to give the vaccine during the day without a parent present. Yes No Call me the week before flu shot is given* Yes No My Child:*(select one) has private insurance has HUSKY/Medicaid has no insurance is Native American or Alaskan Native none of the above Health QuestionsDoes your child have asthma or had wheezing in the last 12 months?* Yes No Is your child allergic to eggs?* Yes No Has your child ever had Guillain-Barre syndrome?* Yes No Is there anyone in the household who has a poor immune system?* Yes No Has your child ever had a flu shot before?* Yes No (If your child is less than 9 years old and never had a flu vaccine, 2 doses are needed one month apart.) Has your child ever had a bad reaction to a flu shot?* Yes No Acknowledgement*Click here to review the Influenza (Flu) Vaccine (Live, Intranasal) information statement. Click here to review the Influenza (Flu) Vaccine (Inactivated or Recombinant) information statement. “I have read or have had explained to me the information about the influenza vaccine from the attached Vaccine Information Statement (VIS). I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request”. Parent/Guardian signature* Today's date* MM slash DD slash YYYY
