Consent Form for Seasonal Flu Vaccine

Dear Parents,
Influenza can be a serious disease for children of all ages; causing them to miss school,
activities or even be hospitalized. The Supreme Council of Health is conducting a school
campaign in which teams will be visiting the schools to vaccinate school children against
seasonal flu. While there are many different flu viruses, the flu vaccine protects against
the three viruses that research suggests will be most common. The 2010-2011 flu vaccine
has been updated to protect against the three flu viruses that experts expect will cause the
most illness.
The dates for the teams visiting the schools will be announced after receiving your reply.
Contraindications:
Severe allergy to eggs or gentamicin
Previous severe reaction to the vaccine
Caution: People with fever should postpone the vaccine until the fever resolves
Adverse effects:
The seasonal flu vaccine is generally safe and the adverse events are limited and include
soreness and swelling at the site of the injection. About 1%-10% of people vaccinated
may develop low grade fever.
Those children 6 months to 8 years who are receiving the vaccine for the first time need
two doses 4 weeks apart.
The Supreme Council of Health urges all parents to make use
of this opportunity to protect their children against influenza
and its complications.
We would like to extend our gratitude and appreciation for
your cooperation with us to protect our community.
Please return the completed consent form to the school as
soon as possible.

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SEASONAL FLU VACCINATION, 2010 -2011
Agree
Students name:
-------------Signature of Parent: -------------------------....../

Class:

Date: ../

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