Parents/Guardians:

Marion County Public Health Department is working with your child’s school to provide Influenza vaccinations at school. Influenza (the flu) is a contagious respiratory illness caused by influenza viruses and not the stomach bug that some people call the flu. It can cause mild to severe illness. Some people, such as older people, young children, and people with certain health conditions, are at high risk for serious flu complications. The best way to prevent the spread of flu is by getting vaccinated each year.

If your child is on Medicaid (Title XIX) or has no insurance coverage for immunizations, the flu vaccination will be given to your child at no cost. If your child meets these guidelines, fill out the enclosed consent form and return to the school nurse by Wednesday, September 27, 2017.

If your child has insurance coverage that pays for immunizations, the cost for the flu shot is $20.00. Hawk-i is private insurance and you will have to pay since we are unable to bill insurance companies. To have your child vaccinated, please fill out the attached consent form and return it with a check/money order in the amount of $20.00 to the school nurse by Wednesday, September 27, 2017.

We will be administering the influenza vaccine at your child’s school in October. Once we set a date, your school will let you know when we will be there.

Please fill out the form completely, paying close attention to the section asking if your child has an allergy to eggs or has ever been diagnosed with Guillian-Barr Syndrome. Without this section completed we will not be able to vaccinate your child. There is also a place you will need to sign, indicating consent for the vaccination and the HIPAA confidentiality clause. If you would like a copy of our HIPAA privacy statement, please contact us. If your child is allergic to eggs or has ever had an allergic reaction to any vaccination you will need to contact your child’s doctor regarding whether or not your child should receive a flu vaccination at school.

Please review the enclosed vaccine information sheet regarding information you need to know about the vaccine to make an informed decision. If you choose not to have your child vaccinated, there is no need to return the consent form. If you change your mind about having your child vaccinated before the scheduled vaccination date, you can contact your child’s school. If your child does not cooperate for the immunization, we will notify you through a letter advising you to take the child to their physician to receive the vaccination, and we will refund your money. Students with a completed consent form will be vaccinated during the school day. Parents or guardians do not have to be there, but are certainly welcome if desired. If you have any questions or concerns, feel free to contact us at (641) 828-2238 and ask for the immunization department, or email Christina at cvanvark@marionph.org.

No vaccine is 100% effective so continue to wash your hands twice through the birthday song, cover your cough, and stay home if you are sick! Sincerely,

Marion County Public Health

Marion County Public Health Department PO Box 152 ● 2003 N. Lincoln

Knoxville, Iowa 50138 Phone: 641.828.2238 Fax: 641.842.3442

CHILD HEALTH IMMUNIZATION ADMINISTRATION FORM School: _____________________

Child’s name:

Male Female

Age Date of Birth

MCO: ___Amerigroup ____AmeriHealth Caritas ____United Healthcare

MCO Member ID: Medicaid #:

Address: City: Zip:

Phone:

Child’s Physician:_____________________________________ Does your child have a usual source of medical care? Yes No Is the usual source of medical care available 24/7 Yes No Does the source of care maintain a record? Yes No Barriers to medical care: _______________________ None

Child’s Dentist:________________________________________ Does your child have a usual source of dental care? Yes No Does the source of dental care maintain a record? Yes No Has your child seen a dentist in the last 12 months? Yes No Barriers to dental care: ______________________ None

Country of Origin: Language: Translator needed: Yes No

Race: White Asian African American Hispanic Native Hawaiian/ Pacific Islander American Indian/Alaska Native Parent Education Level: Monthly Gross Income: Parent Name(s): Family Size:

Please answer the following questions: Please explain any yes answers:

1. Does your child have a developmental delay or disability? Yes No 2. Is your child currently under a physician’s care? Yes No 3. Is your child currently taking any medications? Yes No 4. Does your child have an allergy to eggs or a component of the vaccine? Yes No 5. Has your child ever had Guillain-Barre Syndrome? Yes No 6. Has your child ever had a serious reaction to the influenza vaccine Yes No

in the past? If Yes, explain __________________________________________

A record must be kept in the healthcare provider’s office that reflects the status of all children 18 years of age or younger, who receive immunization through the Vaccines for Children Program. The record may be completed by the parent, guardian or individual of record, or by health care provider. This record should be used for all subsequent visits. While verification of responses is not required, it is necessary to retain this or similar record for each child receiving vaccine.

Child Health Services Consent

Child Health Services may include the following: Assistance Getting Insurance Immunizations

• I have been made aware of the Notice of Privacy Practices on ___________________________________. (insert date)

• I understand that these services are provided through the Iowa Department of Public Health. • I understand that records created and maintained as part of this program are the property of the Iowa Department of Public Health. • I understand that the information from these records may be shared with the Iowa Department of Public Health (Bureau of Family Health

or Bureau of Oral and Health Delivery Systems), Iowa Medicaid Enterprise, or designee for audit and quality improvement purposes or other legally authorized purposes.

• I understand the risks and benefits of the vaccine being given and ask that the vaccine be given to the student for whom I am authorized to make this request. I have had a chance to ask questions which were answered to my satisfaction.

This consent for services is valid for one year unless withdrawn in writing by parent, or guardian, or client (if of legal age).

________________________________________________________________ ___________________ Signature of Parent, Guardian, or Client (if of legal age) Date

I, give Marion County Public Health Department Print name of Parent Print name of agency

consent to provide my child with Child Health Services by a Registered Nurse, Social Worker, or other qualified staff.

Please turn over and complete other side

Indicate the child’s insurance eligibility status (circle only one choice):

(a) My child has private insurance that covers immunizations. (Hawk-i is private insurance) (COST IS $20.00)

(b) Is enrolled in Medicaid

(c) Does not have health insurance

(d) Is American Indian or Alaskan Native (AI/AN)

(e) Is underinsured (has health insurance that does NOT pay for vaccinations) (Can only receive VFC vaccine at a Federally Qualified Health Center [FQHC], rural health clinic [RHC], or local public health agency [LPHA]

For Clinic Use Only: The nurse providing vaccinations will complete the rest of the form.

___________________, a __________(year/month) old child was present and received immunizations today according to the ACIP schedule and for prophylactic vaccination and inoculation against certain viral diseases; _____________________________________________________ ________________________________________________________________________________________________________________________

Were immunizations given at recommended ages? Yes No (if no give explanation with narrative of immunization history) This RN, reviewed immunization history face to face today with family. (describe history, if late/behind, and why?)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

This RN provided vaccination and reviewed with family the following Vaccine Information Statements (VIS) for the following:

FLUZONE 8/7/2015

Date Immunization Dose/Site/Route VIS Edition/Date Lot # This RN provided face to face education & counseling with the family today regarding:

Explained how vaccines work: Vaccines help develop immunity by imitating an infection. This type of infection, however does not cause illness, but it does cause the immunize systems to produce T-lymphocytes and antibodies. Once the imitation infection goes away the body is left with a supply of “memory” T-lymphocytes as well as B-lymphocytes that will remember how to fight that disease in the future.

This RN provided face to face counseling & education today regarding

Flu (influenza) is an illness of the nose, throat, and lungs caused by the influenza virus. It spreads easily and can cause serious problems, especially for very young children, older people and people with certain long-term medical conditions like asthma and diabetes.

Flu vaccine

Save lives

Protects against serious disease

Protects against complications from the flu

Helps protect others

The most common side effects are usually mild and include the following

Redness, swelling, and sore arm form the shot.

Fever, muscle aches

Explained how and when to obtain medical attention: _________________________________________________________________________

________________________________________________________________________________________________________________________

What was family reaction, concerns/questions to education provided: ____________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Next appointment: _____________________________

Nurse Signature: _____________________________________________________ Date: _________________________

Entered into: TAV IRIS Billing Spreadsheet

__Knoxville __Pella Christian __Melcher-Dallas __Pleasantville __Pella __Twin Cedars