Protect your child against Pandemic H1N1 Influenza

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					                                                                                                                                                                                                                   Personal immunization record for pandemic H1N1 influenza vaccine
   Be Informed   All New Brunswickers six months of age and older will be offered the pandemic H1N1 influenza
                                                                                                                                                                                                                   Medicare number:
                 vaccine. All school students may receive this publicly funded vaccine at school as part of the Public
  Protect your   Health Pandemic H1N1 Immunization Program.
                                                                                                                                                                                                                   Student’s name:
                                                                                                                                                                                                                                          Surname                            Given name(s)
                                                                                                                                                                                                                   Date of birth:                                            Gender (M/F)
 child against   What should you know about pandemic H1N1 influenza?             Who should NOT receive the pandemic H1N1 influenza vaccine?      What else should you know?                                       Vaccine name
                                                                                                                                                                                                                                          Year/Month/Day
                                                                                                                                                                                                                                                                   Lot #

Pandemic H1N1    •
                 •
                     H1N1 influenza is caused by a new influenza virus.
                     H1N1 influenza is a respiratory illness with symptoms
                                                                                 •   Children should not receive the influenza vaccine if
                                                                                     they:
                                                                                                                                                  •
                                                                                                                                                  •
                                                                                                                                                      Individuals 16 or older can give their own consent.
                                                                                                                                                      If a student has a fever or illness other than a minor
                                                                                                                                                                                                                   Nurse’s signature:
                                                                                                                                                                                                                   Vaccine name:
                                                                                                                                                                                                                                                                   1st dose date immunized
                                                                                                                                                                                                                                                                   Lot #

   Influenza     •
                     similar to those of regular seasonal influenza.
                     The symptoms begin very quickly and include:
                                                                                       - had a severe allergic reaction to the seasonal
                                                                                           influenza vaccine.
                                                                                       - have a severe allergy to eggs or any of the
                                                                                                                                                  •
                                                                                                                                                      cold, the nurse may delay immunization.
                                                                                                                                                      It is important to answer all questions on this consent
                                                                                                                                                      form.
                                                                                                                                                                                                                   Nurse’s signature:                              2nd dose date immunized
                                                                                                                                                                                                                   This immunization record will be given to the student after his/her immunization.
                                                                                                                                                                                                                   Keep this record in your personal health files.
                        - fever and cough, and one or more of the
                           following:                                                      ingredients of the vaccine or its container.           •   If a student has an allergic reaction to a vaccine, or
                              › sore throat, joint or muscle pain or fatigue.          - are younger than six months of age.                          if you have any questions, contact the public health         Consent form for pandemic H1N1 influenza vaccine
                                                                                                                                                      office.
                        - children younger than five may have                                                                                                                                                      Medicare number:
                           gastrointestinal symptoms.                            What to expect following pandemic H1N1 immunization?             •   The vaccine is safe and highly recommended to be
                                                                                                                                                      given in pregnancy. Female students must tell the nurse      Student’s name:
                        - persons younger than five or persons 65 and            •   Redness, discomfort, and swelling at the injection site                                                                                              Surname                            Given name(s)
                                                                                     may last up to two days.                                         if they think they may be pregnant.
                           older may not necessarily have a fever.                                                                                                                                                 Birth date:
                                                                                 •   Fever, fatigue and muscle aches may last for up to two       •   Immunization records are not confidential. If your                                    Year/Month/Day
                 •   Complications of H1N1 influenza include pneumonia,                                                                               family doctor requests your immunization records we
                     respiratory failure, worsening of chronic medical               days.                                                                                                                         Does the student identify as First Nation/Aboriginal? Yes          No
                                                                                                                                                      will provide it.
                     conditions and death.                                       •   As is the case with any vaccine, there is an extremely                                                                        Is the student pregnant? Yes           No
                                                                                     small chance that a more serious reaction may occur.         •   Report to the local public health office or see your         Does the student have a medical condition? Yes            No
                 •   The H1N1 influenza is spread the same way as the                                                                                 doctor if your child has a severe or unusual reaction        If yes, please state:
                     seasonal influenza:                                         •   Children are asked to remain on site for at least 15             during the four weeks after the vaccine.
                                                                                     minutes after the vaccine is given so that possible                                                                           Did the student receive a seasonal influenza vaccine (flu shot) this year? Yes      No
                        - germs enter the nose and/or throat and spread                                                                           •   All parents/guardians/students are asked to complete         If Yes, how many doses of the seasonal flu vaccine did he/she receive?
                           from person to person through the air via                 reactions can be monitored.
                                                                                                                                                      the tear-off portion of this brochure and return it to the                       1 dose only          2 doses
                           coughing and sneezing; or through direct contact                                                                           school, even if the student will not be immunized. This
                           with contaminated hands and surfaces.                 What if my child has a reaction to the pandemic H1N1 influenza                                                                    Does the student have any allergies? Yes           No
                                                                                                                                                      is important for maintaining accurate records.
                 •   Influenza is considered contagious for as long as seven     vaccine?                                                                                                                          If yes, please state:
                     days following the beginning of the illness, particularly   •   A cold compress on the injection site may reduce                                                                              Parent/Guardian:
                                                                                                                                                  How to register for this program
                     when the symptoms are present.                                  discomfort.                                                                                                                   Daytime telephone number:
                                                                                                                                                  •   Complete and sign the tear-off section of the brochure.
                                                                                 •   For discomfort and fever, children may be given                                                                               I have read or had explained to me the information about the vaccine. I believe I
                                                                                                                                                  •   Return the completed tear-off section to the school.         understand its benefits, risks, side-effects and reasons why the above-named student
                 What should you know about the pandemic H1N1 vaccine?               acetaminophen or ibuprofen (for example: Tylenol or
                                                                                     Advil).                                                      •   Keep the rest of the brochure for your information.          may or may not receive the vaccine. I have had the opportunity to ask questions to a
                 •   It is similar to the seasonal influenza vaccine and is                                                                                                                                        health-care provider, who answered all of my questions to my satisfaction.
                     made the same way.                                          •   Aspirin (ASA) should NOT be given to children younger        •   Once the student is fully immunized, the nurse will
                                                                                                                                                                                                                   Please check appropriate box:
                 •   The vaccine is made of killed H1N1 influenza virus and          than 18 due to its link to Reye Syndrome.                        complete the Personal Immunization Record and return
                                                                                                                                                      it to that student.                                              Yes, please immunize the above-named student with two doses of vaccine against
                     cannot cause H1N1 influenza.                                                                                                                                                                  the pandemic H1N1 influenza virus.
                 •   The vaccine contains an adjuvant (additive) that makes                                                                                                                                            No, please do not immunize the above-named student against the pandemic H1N1
                     the vaccine work better. Adjuvants are used in other                                                                         For more information                                             influenza virus.
                     vaccines.                                                                                                                    •   Contact the local public health office.                      Reason:
                 •   The vaccine is given by injection into the arm.                                                                              •   Government of New Brunswick: www.gnb.ca/flu.                 Date:                                Signature:
                 •   Children may need two doses of the vaccine to obtain                                                                                                                                                                                                  (student/parent/guardian)
                     adequate protection.                                                                                                         CNB 6543/10/2009

				
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posted:4/1/2010
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