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2. CONSENT AND ADMINISTRATION RECORD

   SCHOOL-BASED IMMMUNIZATION EXERCISE | 104 S. EYDER AVE., PHILLIPS, WI 54555

4. Child's First Name *
5. Child's Last Name *
6. Middle Initial
8. Telephone Number *
9. Child's Date of Birth*
   Child's Date of Birth
10. Child's Age*
11. Gender *

    1. Female
    2. Male
13. Address*
14. City*
15. State*
16. Zip Code *
18. Please select the school your child attends*
    -- Select One --Chequamegon - Glidden CampusChequamegon - Park Falls CampusPhillipsPrentice
19. Please select the grade your child is in *
    -- Select One --4KKindergarten1st2nd3rd4th5th6th7th 8th9th 10th 11th12th
21. Is the person vaccinated sick today? *

    1. Yes
    2. No
22. Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine?*

    1. Yes
    2. No
23. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*

    1. Yes
    2. No
25. Has the person to be vaccinated ever had Guillain-Barré syndrome?*

    1. Yes
    2. No
26. Has the person to be vaccinated ever felt dizzy or faint before, during, or after a shot?*

    1. Yes
    2. No
27. Is the person to be vaccinated anxious about getting a shot today?*

    1. Yes
    2. No
29. If you answered yes to any of the questions listed above, please explain:

31. I have been given a copy and have read, or have had explained to me, information about influenza and the influenza vaccine to be received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine be given to the person named above for whom I am authorized to make this request. I understand that if I am a BadgerCare recipient I cannot be charged an administration fee or asked for any type of donation for the administration of the influenza vaccine. Information on this form will be used to document receipt of the influenza vaccine in the Wisconsin Immunization Registry (WIR). My signature below authorizes my child to receive the initial dose of the influenza vaccine and if needed, a booster dose.

33. Electronic Signature Acknowledgement *

    I wish to submit this influenza administration form by electronic means. By signing this permission form, I certify, that my answers are correct and complete to the best of my knowledge. I understand the questions and statements on this permission form. I understand that an electronic signature has the same legal effects and be enforced the same way as a written signature.

    1. By checking this box and typing my name below, I am electronicaly signing the influenza administration permission form.
35. Electronic Signature *
36. Date*
    Date
40. FOR OFFICE USE ONLY
42. Vaccine Information

    VIS Date: 1/31/2025

    Manufacturer: Sanofi Pasteur

    Route: IM

    Dosage: 0.5ml

    Exp: 6/30/2026

43. Vaccine Lot number

    1. Fluzone Trivalent P-Free | Lot #U8881DA
44. Site

    1. RD
    2. LD
    3. RV
    4. LV
46. Signature of Vaccine Administrator:
47. Date:
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field