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7 Promoting and protecting the health ofthe public and the environme October 30, 2008 Dear Parents, The Fairfield Country Health Department is pleased to have the opportunity to partner with Richard Winn Academy and offer influenza (flu) vaccine to its students, faculty, and staff. Flu takes a big toll on young children, Each year in the United States, an average of 20,000 children younger than 5 are hospitalized because of flu-related complications. As many as 1 in 5 children under age 5 may have to see the doctor, visit the ER or other urgent care for treatment for flu. And tragically, around 100 children die from this serious disease each year. That is why the Centers for Disease Control and Prevention (CDC) recommends that children older than 6 months get vaccinated against the flu. CDC also recommends that close contacts, especially family members and caregivers, of children younger than 5 get a flu vaccine each year to provide added protection to this high- risk group. The flu is a contagious disease that can cause symptoms such as high fever, sore throat, coughing, extreme tiredness, runny or stuffy nose, and even nausea and diarrhea in children. It can easily spread from person to person. Yearly flu vaccination should begin as soon as vaccine is available and continue throughout the flu season, into December, January, and beyond. Vaccination is the single best protection against the flu. Enclosed, you will find a copy of the Permission slip, a Vaccination Administration Record (3518), a Clients Bill Of Rights, and a Vaccine Information Sheet (VIS). Please complete the permission slip and the following parts of the Vaccination Administration Record (351 Alternate Method of Contact (top of page) Parent/ Legal Guardian signature (mid page). The influenza vaccine will be provided to all students FREE of charge on November 14", 2008 beginning at 7:30 am. Thank you for the opportunity to vaccinate your child. The Fairfield Country Health Department and the RWA staff welcome and strongly encourage you to be present with your child during vaccination. SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL Region3 Serving Chester, Fairfield, Lancaster, Lexington, Newberry; Richland and York C Columbia Public Health Office * 2000 Hampton Street + Columbia, SC29204 * Phone: (808) 576 XK) * wwwscdhecgov ia ee ar Hamer C Please Print Clearly SEX MALE__FEMALE__ RACE CAUCASIN AFRICAN AMERICAN __ HISPANIC ASIAN) eee OTHER UNDER 19 YRS. OF AGE CIRCLE ONE MEDICAID YES NO PRIVATE INS/HMO YES NO PAYS 100% FOR IMMUNIZATIONS YES NO I give the Fairfield County Health Department Nurse permission to administer the Flu vaccine to my child at Richard Winn Academy. x (PARENT/GUARDIAN SIGNATURE) I do not give the Fairfield County Health Department Nurse permission to administer the Flu vaccine to my child at Richard Winn Academy. x. (PARENT/GUARDIAN SIGNATURE) Ihave read the Flu VACCINE INFORMATION SHEET (VIS) and have no questions. x, (PARENT/GUARDIAN SIGNATURE) My child is not allergic to EGGS OR ANY OF THE CONTENTS OF THE FLU VACCINE. x (PARENT/GUARDIAN SIGNATURE) ‘My child has had a Flu shot before, © WHEN/YEAR, 1 DOSE. 2 DOSES. Ifyour child is under the age of 9 years and this is his/her 1" Flu shot, he/she will need a second dose in 30 days (1 month), Please contact the Fairfield County Health Department at 803-635-6481 for an appointment or see your Private Medical Doctor. vite and encourage parents of younger children to accompany his/her ehild during ination. Getting a Flu shot is the best way to prevent the Flu! i SOUTHE ONTROL EPARYMI ENVIR LINA Region Serving Chester, Fairfield, Lancaster, Lexington, Newber (Columbia Public Health Office + 2000 Hampton Street * Columbia, SC2 Richlandand York Counties 124 + Phone:(808) 576-2900 + wwwsclicegor F_C ‘Adult immunization Program Vaccine Administration Record Name Date of Birth ‘Street Address, City, State, Zip ‘Telephone Race | Sex —— ___| mj FO = = Preferred Method of Contact: cat TC] Yes CI No Mail [Yes [1] No Preferred PhonelAddress (fdiferentfrom above) oe ‘Aternate Method of Contact: 7 a Emergency Contact: : Emergency Phone: Medicare Card Number — (incase aiphe wn) (1 Medicaid Card Number ___ (1 Other insurance: Company __. Policy Number Name and Si of Policy Holder ‘The client Bill of Rights has been reviewed with the client or client's legal guardian? [_] Yes Billing Certification & Privacy Notice ‘By my signature below as parent, guardian or client, | request that payment of Medicare/Medicaid or other Third Party Insurance benefits be made on behalf of the South Carolina Department of Health and Environmental Control for any services provided me. Permission is also granted to DHEC to exchange medical or other confidential information as necessary tothe Center For Medicare and Medicaid Services (CMS), its agents or other agents needed to determine these benefits for related services. applicable, | also agree to participate in treatment plans, assignment of insurance, Medicaid or Medicare benefits to DHEC for services rendered and to participate in payment for services as determined by specific program guidelines. acknowledge that | have been provided with a copy of DHEC's Privacy Notice. Patient refused notice?[_] Yes Signature (GiontlLegal Guardian) Tae “Wines (idiontagnawiiX) SSCS INJECTION | INJECTION vis \VACCINENAME JECTION |NJECTION MANUFACTURER | LOTICONTROL# | opMS .r— INFLUENZA (FLU) PNEUMOCOCCAL POLYSACCHARIDE (ePvz3) TETANUS (TA) ‘Signature and Title of Person Administering Vaccine(s)/Date Clinic Site or Health Department | ‘AEC 3518 (1209) Sah A ‘SOUTH CAROLINA DEPARTMENT OF HEALTITAND ENVIRONMENTAL CONTROL