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St. James' CE Primary School

Flu Immunisation Consent Form 2020

Section 1 - Student Details


Section 2 - Consent (please confirm YES or NO by marking in one box only

Select ONE of the following:*

Section 3 - Child's health questions (only complete if consenting to the nasal flu vaccine)

Has your child been diagnosed with Asthma?
If Yes, has your child taken steriod tablets because of their asthma within the past two weeks?
Has your child ever been admitted to intensive care because of their asthma?

Please let the immunisation team know if your child has to increase their asthma medication prior to the Immunisation session taking place at school.

Has your child already had the flu vaccine in the last 6 months?
Does your child have a disease or treatment that severely affects their immune system? (eg treatment for leukaemia)
Is anyone in your family currently having treatment that severely affects their immune system? (eg they need to be kept in isolation)
Does your child have a severe egg allergy? (needing intensive care)
Is your child receiving salicylate mediation? (needing intensive care)

Section 4 - to be completed by person with parental responsibility