Nurse Instruction Booklet - Favorite Medical Staffing Agency

Nurse Instruction Booklet

235 HEMBREE PARK DRIVE, SUITE 300
ROSWELL, GA 30076

Phone (770) 512-8566 ! Fax (770) 512-8558
www.flubusters.net

TABLE OF CONTENTS 3
4
What Is In My Supplies Box? 5
Check In 6-7
Flu Consent Forms 8–10
Administering Vaccine
Accepting Payment 11
12
(including Medicare and Vouchers) 13
14-15
Check Out 16
Returning Paperwork & Supplies 17
Frequently Asked Nursing Questions 18
Emergency Procedures 19
Credit Card Authorization Form 20-21
Medicare Information Form
Influenza Consent Form
Pneumonia Consent Form
VIS Form

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 2

WHAT IS IN MY SUPPLIES BOX?

SHIPPING MATERIALS LIST:
Each number corresponds with the following item…

#1 = Outermost shipping box containing all clinic supplies
#2 = Epinephrine in red bag (to remain at room temperature)
#3 = Vaccine Cooler (contains cold packs and vaccine inside)
#4 = Needles
#5 = Gloves
#6 = Band-Aids
#7 = Alcohol Pads
#8 = Gauze Pads
#9 = Pouch/Bag for completed Consent Forms
#10 = Pouch/Bag for all cash, completed credit card forms, checks and completed

Medicare forms
#11 = Envelope containing Clinic Summary Sheet
#12 = Nurse Instruction Booklet
#13 = SHARPS Container

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 3

1. CHECK IN

! Please locate the box of clinic supplies labeled #1 from the site
contact and ensure all materials are accounted for (#2 through #13
inside the supply box) when you arrive at the clinic site.

! Locate the cold packs inside box #3 and place at least one in the
freezer with the site contacts permission and the remainder should
stay inside #3 to keep vaccine cool throughout clinic.
DO NOT THROW BOX #3 AWAY!

! Ask the site contact for the vaccine bag from the refrigerator.
! Call the Flu Busters Nursing Department at (866) 363-0955 for further

instructions. Our team will also record your exact arrival time to make
sure your hours are accounted for to be paid!

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 4

2. FLU CONSENT FORMS

! You MUST collect the signed consent form from each patient BEFORE
administering his/her shot!

- If you are at a grocery store or pharmacy, two part consent forms
are included in your shipment. Please give the duplicate copy to the
recipient for his/her records.

- If you are at a corporation (non-grocery store or non-pharmacy),
the participants should already have their consent forms ready for
you. If the participants do not have consent forms, please
respectfully ask the site contact to make copies of the consent form
on page 16 for the influenza vaccination and page 17 for any
pneumonia vaccinations (if applicable) for each participant.

- There is a flu consent form on page 16 inside this booklet in
case you need to make copies.

- There is a pneumonia consent form on page 17 inside this
booklet in case you need to make copies.

! Please ensure each patient has filled in the appropriate information
and signed his/her consent form.

! Please make sure to mark the following information on each consent
form:

- Circle either right deltoid or left deltoid
- Enter the lot number, expiration date and manufacturer number of
the vaccine you are administering to the patient (located on each
vaccine vial)

! All consent forms must be collected, bound with provided binder clips
and placed in pouch labeled #9.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 5

3. ADMINISTERING VACCINE

! Each shot should contain 0.5 ml dose
(there are 10 to 11 doses in each vial).

! Please use new, fresh gloves for each injection!

SAFETY SYRINGES: If your clinic includes safety syringes, please follow
the instructions on the next page (page number 7) inside this booklet.
EMERGENCY PROCEDURES: Please call 911, contact Flu Busters and see
pages 14 and 15 inside this booklet.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 6

SAFETY SYRINGES - Instructions for Use

This device is sterile unless the package has been damaged or opened.
This is a single use item only.
PREPARATION FOR DOSING

Peel package to allow removal of Safety Syringe. Remove the needle cap.
Do not fully push the plunger before drawing vaccine to prevent premature activation
of the safety syringe. If you hear a “click”, the plunger has been depressed, the
safety syringe has then been activated and will be unable to draw any vaccine and be
unusable.
DOSE ADMINISTRATION

Draw the medication and expel the air bubbles using standard clinical technique.
Prepare injection site and administer dose using standard technique.

Once vaccination is administered, depress plunger fully. You will hear a “click”
indicating the plunger is fully depressed and locked to the actual needle in order to
be retracted. Needle cannot be retracted if plunger is not fully depressed.

Plunger Fully Depressed Plunger NOT Fully Depressed

Retract the plunger and needle holder base together until an obvious stop is felt.
Snap off the plunger and discard BOTH parts in the provided and approved SHARPS
container after each vaccination.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 7

4. ACCEPTING PAYMENT

! Flu Busters accepts Cash, Credit, Check and Medicare Part B!

CASH: At the conclusion of the clinic, any cash collected must be
converted back into a money order made out to Flu Busters and sent back
along with all other paperwork. Please place this in pouch labeled #10.

CREDIT: Locate credit card information form. If you need to make a copy
of this form for participants, there is a form to make copies with on page
18 of this booklet. All information must be legible and complete! If you
are unsure where the 3 to 4 digit code is located on the card, here is
where to find it:

Keep the signed authorization and group all credit card payments
together with provided binder clip. Please place this in pouch labeled
#10.

CHECK: All checks should be made out to Flu Busters in the exact amount
only. Please group all checks together with provided binder clip. Please
place this in pouch labeled #10.

(information about accepting Medicare on next page)

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 8

MEDICARE PART B: Flu Busters only accepts Medicare Part B; this must
be the patient’s primary insurer to be accepted! If this is not the case,
the patient must pay for his/her vaccination. Each participant must
submit a legible photocopy of his/her Medicare Part B card and give to
you before receiving the vaccination. If you need to make a copy of this
form for participants, there is a form to make copies with on page 19 of
this booklet. Please group all Medicare Part B copies submitted for
payment together with provided binder clip. Please place this in pouch
labeled #10.
Cards must look like this (only these cards will be accepted!):

(information about accepting vouchers on next page)

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 9

! Flu Busters also accepts vouchers to serve as payment!
VOUCHERS: Flu Busters accepts vouchers to serve as a form of payment
this year. If a participant would like to pay with a voucher, please collect
the voucher. At the conclusion of the clinic, please group all vouchers
together and place this in pouch labeled #10.
Vouchers must look like this (only these cards will be accepted!):
Front:

Back:

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 10

5. CHECK OUT!

! Locate “Clinic Summary Sheet” inside the envelope labeled #11.

! Count the number of consent forms collected and enter this number on
the Clinic Summary Sheet.

- Upon Flu Busters receipt of all supplies, our team will also count the
vaccine for cross reference.

! Count the number of full and partial vials remaining; enter this
number on Clinic Summary Sheet.

! Count the amount of money collected keeping each form of payment
separate (cash, credit/debit cards, checks, medicare); enter all
information on the Clinic Summary Sheet.

! Fill in any other pertinent information related to this clinic on the
Clinic Summary Sheet and have the site contact sign it.

! Once the above steps are completed, call Flu Busters Nursing Team at
(866) 363-0955 for final instructions. DO NOT pack any supplies until
you call Flu Busters; our team will help you pack all supplies
appropriately and we will check you out (and make sure your hours are
accounted for to be paid!).

! After speaking with a Flu Busters Nursing Team Representative:
1. Place the completed Clinic Summary Sheet inside the envelope
labeled #11 and seal!
2. Place sealed Clinic Summary Envelope labeled #11 inside pouch
#10 with the monies.
3. Please seal both pouches (#9 containing the Consent Forms and #10
containing all other Forms and Monies and Clinic Summary
Envelope).
4. Place both pouches into the box labeled #1 to be returned to Flu
Busters.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 11

6. RETURNING PAPERWORK & SUPPLIES

! ALL supplies will need to be returned to Flu Busters EXCEPT the
SHARPS container (#13). The SHARPS container MUST be handled by
you only! Please ask permission from site contact to leave SHARPS
container in their mail room or other appropriate mail pick-up
location. The box containing the red SHARPS container already has
pre-paid postage (no additional postage label is needed) to be mailed
through US Mail only.

! Please make sure ALL items #2 through #12, are placed back in the
original shipping box labeled #1 and returned to Flu Busters. Clear
shipping tape strips are located on the inside flap of the original
shipping box (#1) for you to tape the box for final shipping.

! Please affix the provided return shipping label located inside this
binder to the outermost box labeled #1 to be shipped directly back to
Flu Busters headquarters.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 12

FREQUENTLY ASKED NURSING QUESTIONS

! What size are the needles?

The size of the provided needles are 1”, 25G (one inch, 25 gauge).

! What is a safety syringe and how does this work?

A safety syringe is a single use syringe and needle where the needle is able to retract
into in the syringe once the shot is administered. This type of syringe and needle
system was invented to decrease the risk of accidental needle stick. Please see the
instructions located on the “Administering Vaccine” page of this instruction manual
for usage information.

! What age range is Flu Busters vaccine approved for?

All Flu Busters vaccine is approved for participants 18 years of age and older.

! What if a participant is pregnant?

All pregnant women, or women planning to conceive in the next year, should bring a
doctor’s note in order to receive the flu vaccination. The doctor’s note should be
attached to this patient’s consent form and returned to Flu Busters.

! If the participant is currently sick, can he still receive the flu shot?

If a participant is currently sick, he/she should not receive the flu vaccination until
completely well.

! Does the vaccine contain thimerosal?

Flu Busters flu vaccine does contain a trace amount of thimerosal.

! Does the vaccine contain animal products?

Yes, the vaccine is grown and developed inside hens’ eggs.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 13

EMERGENCY PROCEDURES!

Medical Management of Vaccine Reactions in Adult Patients

All vaccines have the potential to cause an adverse reaction. To minimize adverse reactions,
patients should be carefully screened for precautions and contradictions before vaccine
administrated. Even with the careful screening, reactions (e.g. anaphylaxis) can happen. If
reactions occur, staff should be prepared with procedures for their management. The table
below describes procedures to follow if various reactions occur.

Reaction Symptoms Management

Localized Soreness, redness, itching, or Apply a cold compress to the injection site.
swelling at the injection site Consider giving an analgesic (pain reliever)
or antipruritic (anti-itch) medication

Slight Bleeding Apply an adhesive compress over the
injection site.

Continuous bleeding Place a thick layer of gauze pads over site
and maintain direct and firm pressure; raise
the bleeding injection site (e.g. arm) above
the level of the patient’s heart.

Psychological Fright before injection is given Have patient sit or lie down for the
fright and vaccination
syncope Extreme paleness, sweating,
(fainting) coldness of the hands and feet, Have patient sit with head between knees
nausea, light-headedness, for several minutes. Loosen any tight
dizziness, weakness, or visual clothing and maintain an open airway. Apply
disturbances. cool, damp cloths to the patient’s face and
neck

Fall, without loss of consciousness Examine the patient to determine if injury is
present before attempting to move the
patient. Place patient flat on back with feet
elevated

Anaphylaxis Loss of consciousness Check the patient to determine if injury is
present before attempting to move the
Sudden or gradual onset of patient. Place patient flat on back with feet
generalized itching, erythema elevated. Call 911 if the patient does not
(redness), or urticaria (hives); recover immediately.
angioedema (swelling of the lips, See “Emergency Medical Protocol for
face, or throat); severe Management of Anaphylactic Reactions in
bronchospasam (wheezing); Adults” on the next page for detailed steps
shortness of breath; shock; to follow in treating anaphylaxis.
abdominal cramping; or
cardiovascular collapse (continued on next page)

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 14

Emergency Medical Protocol (continued from previous page)
For Management of Anaphylactic Reactions in Adults

SUPPLIES NEEDED
! Aquesous epinephrine 1:1000 (i.e., 1mg/mL) dilution, in pre-filled syringes, including

epinephrine auto-injectors (e.g., EpiPen). If EpiPens are stocked, at least three adult EpiPens
(0.3mg) should be available.
! Wristwatch or second-hand
! Alcohol Swabs
! Cell Phone or access to an on-site phone

SIGNS & SYMPTOMS OF ANAPHYLACTIC REACTION
Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives);
angioedema (swelling of the lips, face, or throat); severe bronchospasam (wheezing);
shortness of breath; shock; abdominal cramping; or cardiovascular collapse

TREATMENT IN ADULTS

! If itching and swelling are confined to the injection site where the vaccination was given,
observe patient closely for the development of generalized symptoms

! If symptoms are generalized, activate the emergency medical system (EMS; e.g., call 911.)
This should be done by a second person, while the primary nurse assesses the airway,
breathing, circulation, and level of consciousness of the patient.

! Administer aqueous epinephrine 1:1000 dilution intramuscularly, 0.01 mL/kg/dose (adult dose
from 0.3 to 0.5 mL, with maximum single dose of 0.5 mL).

! Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation (CPR), if
necessary, and maintain airway. Keep patient in a supine position (flat on back) unless he or
she is having difficulty breathing. If breathing is difficult, patient’s head may be elevated,
provided blood pressure is adequate to prevent loss of consciousness. If blood pressure is low,
elevate legs. Monitor blood pressure and pulse every 5 minutes.

! If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every 10-20
minutes for up to 3 doses, depending on the patient’s response.

! Record all vital signs, medications administered to the patient; include the time, dosage,
response, and the name of the medical professional who administered the medication, and
other relevant clinical information.

! Notify patient’s primary care physician.
! Once patient has left the scene, complete and file a Vaccine Adverse Event Reporting System

(VAERS)* form, or call VAERS at 1-800-822-7967.

! Call Flu Busters and ask for the nurse staffing manager at (866) 363-0955 and report incident.

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 15

CREDIT CARD AUTHORIZATION

ALL information MUST be filled out!
We ONLY accept VISA and MASTERCARD
Nurse: Please record ALL information before the shot is administered!

Amount Charged to Card: $ ________ Today’s Date: _________________

Name on Credit Card – please print:

_________________________________________________________________________________________________

Company Name on Credit Card – if applicable, please print:

_________________________________________________________________________________________________

Credit Card Information

Credit Card Type - # Visa # MasterCard Exp. Date ______/______/______

Credit Card Number __________________________________________ 3 - 4 digit code ___________

(on back of card)

Billing Address

Street _________________________________________________________________________________________

City ______________________________________________ State ____________ Zip _____________________

Phone: ( ) ______________________________

Email Address: _______________________________________________________________________________
(email address will never be disclosed to another party)

Patient’s Signature: _______________________________________________ Date: ________________

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 16

MEDICARE INFORMATION FORM

All information MUST be filled out to qualify!

Patient’s Name – EXACTLY as it appears on your Medicare Card:
_____________________________________________________________________

Patient’s Medicare Card Number – ALL numbers and letters:
_____________________________________________________________________

Date of Birth: ______ / ______ / ______
Sex – circle one: M F

Home Address

Street ________________________________________________________________

City _________________________________ State _________ Zip ______________

Phone: ( ) _____________________ Email: ___________________________

Where did you receive your flu shot?
Store Name ___________________________________________________________
City _________________________________ State _________

Patient’s Signature: ________________________________ Date: _____________

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 17

FLU BUSTERS
CONSENT, RELEASE AND WAIVER OF LIABILITY – INFLUENZA VACCINE

This Consent, Release and Waiver of Liability is executed this _____ day of ___________, 20__, by you, the undersigned
employee (“Employee”), in favor of your Employer, _________________________, and its directors, officers, employees, and agents,
and Care Dynamix, LLC, a Georgia limited liability company, d/b/a “Flu Busters,” (“Flu Busters”), and its directors, officers, employees,
and agents.

I hereby freely and voluntarily, without duress, execute this Consent and Release under the following terms:

1. The Influenza Vaccine. The flu can cause illness and great discomfort, and in some people can become life threatening. For this
reason, the flu vaccine is available and recommended for people at increased risk of developing complications from the flu – particularly
people aged 65 and older, people with certain chronic medical conditions and anyone who works in close contact or lives with person at
high risk. If you question whether you should receive the flu vaccine, you should contact your personal physician. The flu vaccine,
which is made from dead influenza viruses, cannot give you the flu. This year’s vaccine will protect against the following strains of
influenza: A/Solomon Islands/3/2006 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like viruses

2. Possible Side Effects and Adverse Reactions. A small percentage of those vaccinated may experience minor side effects, such as
soreness around the vaccination site for up to two days, headache or low-grade fever. Immediate, presumably allergic, reactions such as
hives, angioedema, allergic asthma or anaphylaxis occur rarely after influenza vaccination. These reactions probably result from
hypersensitivity to some vaccine component – the majority of reactions are most likely related to residual egg protein. Individuals with
anaphylactic hypersentsitivty to eggs should not be given an influenza vaccine. Guillian-Barre Syndrome (“GBS”) was noted to be a
rare sequel of influenza vaccination during the 1976 “swine” influenza immunization program. Recent information does not indicate a
clear risk of GBS in recipients of the flu vaccine compared to non-vaccines. (Additional information relating to adverse reactions and
side effects will be provided upon request.) Please contact your personal physician in the event of a reaction. Because of the potential
for allergic reaction you are asked to remain in the immediate area for observation purposes for the next 20 minutes after
receiving the vaccine.

You must answer the following questions prior to receiving the vaccine (Check yes or no). Yes " No "
a. Are you allergic to chicken eggs, mercury or Yes " No "

sensitive to sulfites (found in cheese, wine, salads)? Yes " No "
b. Do you currently have an acute infection or fever?
c. Have you ever had a severe reaction to a flu shot? Yes " No "
d. Are you pregnant or currently nursing a baby?
e. Do you have a severe blood clotting disorder? Yes " No "
f. Have you received any other vaccine within the past 14 days? Yes " No "

If you answered “yes” to any of the above, it may be inappropriate for you to receive the flu vaccine today. Please consult with your
physician.

3. Waiver and Release. I hereby release and forever discharge and hold harmless FluBusters, and its directors, officers, employees,
agents and assigns, and Employer, and its directors, officers, employees, agents and assigns (hereinafter, collectively referred to as
“Releasees”) from any and all liability, claims, demands, and causes of action, of whatever kind or nature, either in law or equity, which
may hereafter arise from my receipt of the flu vaccine. I understand and acknowledge that this Consent and Release discharges
Releasees from any liability or claim that may arise as a result of my receipt of the flu vaccine, with respect to any bodily injury or other
injury, including any mental injury, illness, death, or property damage that may result. I understand that Releasees do not assume any
responsibility or obligation to provide financial assistance or other assistance, including, but not limited to medical, health, or disability
insurance, in the event of injury, illness, death or property damage, unless otherwise expressly provided.

4. Other. I expressly understand and agree that this Consent and Release is intended to be as broad and inclusive as permitted by law,
and this Consent and Release shall be governed by and interpreted in accordance with the laws of the State of Georgia. I agree that in the
event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such
clause or provision shall not affect the remaining provisions of this Consent and Release.

5. Informed Consent. I have read the above Consent and Release and understand its provisions and applicability. I understand the
benefits and risks of the flu vaccine as described and request that the vaccine be given to me.

______________________________ ______________________
Name Date

______________________________ ______________________
Signature Date

______________________________
Signature of Parent/Guardian

Lot # ___________________ SITE: RD LD
Expiration Date___________ Manufacturer:

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 18

CARE DYNAMIX, LLC d/b/a FLU BUSTERS
CONSENT, RELEASE AND WAIVER OF LIABILITY – PNEUMONIA VACCINE

This Consent, Release and Waiver of Liability is executed this _____ day of ___________, 20__, by you, the undersigned
(“Recipient”), in favor of the clinic site sponsor, and its directors, officers, employees, and agents (“Company”), and Care Dynamix,
LLC, a Georgia limited liability company, d/b/a Flu Busters (“Flu Busters”), and its directors, officers, employees, and agents.

I hereby freely and voluntarily, without duress, execute this Consent, Release and Waiver of Liability under the following
terms:

1. The Pneumonia Vaccine. The pneumonia vaccine is composed of 23 of the most prevalent pneumococcal types of Strep. The
pneumonia vaccine will not give you pneumonia. It is given by injection. As with any medication, there are risks and possible side
effects/reactions. Side effects of the pneumonia vaccine are generally mild in adults and occur within 6 to 12 hours after vaccination and
can persist for one or two days. These reactions consist of soreness of the injection site, fever, chills, muscular aches, and, in rare cases,
death. Immediate, presumably allergic, reactions such as hives, angioedema, allergic asthma or anaphylaxis occur rarely after the
pneumonia vaccine. These reactions probably result from hypersensitivity to some vaccine component. If you should have a reaction,
you should contact your physician. Because of the potential for allergic reactions, you are asked to remain in the immediate area
for observation purposes for the next 20 minutes after receiving the vaccine.

You must answer the following questions prior to receiving the vaccine (Check yes or no).

a. Have you ever had a Pneumonia shot before? Yes " No "
If so, when?
Yes " No "
b. Are you currently receiving chemotherapy, radiation therapy or immunosuppressive therapy Yes " No "
or are you having these therapies within the next two weeks? Yes " No "
Yes " No "
c. Are you pregnant (Flu Busters does not vaccinate pregnant women)?
d. Are you currently nursing (Flu Busters does not vaccinate nursing women)? Yes " No "
e. Have you ever had an adverse reaction to another vaccine? Yes " No "
Yes " No "
Please list the adverse reaction Yes " No "
f. Do you have a past history of Guillain-Barre syndrome? Yes " No "
g. Do you have any hypersensitivity to any component of the vaccine? Yes " No "
h. Are you allergic to neomycin, thimerosal or streptomycin? Yes " No "
i. Do you have a history of sensitivity to latex? (refers to gloves and rubber stopper)
j. Have you had Pneumonia within the past year?
k. Are you currently receiving any blood thinners such as coumadin or heparin?
l. Do you currently have a fever or respiratory illness or any other type of infection?

If you answered “yes” to any of the above, it may be inappropriate for you to receive the pneumonia vaccine today. Please consult with
your physician.

2. Waiver and Release. I hereby release and forever discharge and hold harmless Flu Busters, and its directors, officers, employees,
agents and assigns, and Company, and its directors, officers, employees, agents and assigns (hereinafter, collectively referred to as
“Releasees”) from any and all liability, claims, demands, and causes of action, of whatever kind or nature, either in law or equity, which
may hereafter arise from my receipt of the pneumonia vaccine. I understand and acknowledge that this Consent and Release discharges
Releasees from any liability or claim that may arise as a result of my receipt of the pneumonia vaccine, with respect to any bodily injury
or other injury, including any mental injury, illness, death, or property damage that may result. I understand that Releasees do not
assume any responsibility or obligation to provide financial assistance or other assistance, including, but not limited to medical, health,
or disability insurance, in the event of injury, illness, death or property damage, unless otherwise expressly provided.

3. Other. I expressly understand and agree that this Consent and Release is intended to be as broad and inclusive as permitted by law,
and this Consent and Release shall be governed by and interpreted in accordance with the laws of the State of Georgia. I agree that in the
event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such
clause or provision shall not affect the remaining provisions of this Consent and Release.

4. Informed Consent. I have read the above Consent and Release and understand its provisions and applicability. I understand the
benefits and risks of the pneumonia vaccine as described and request that the vaccine be given to me.

______________________________ ______________________
Name Date

______________________________ ______________________
Signature Date

______________________________
Signature of Parent/Guardian

Lot # __________________ Site LD/RD Paid Customer
Expiration Date__________
Manufacturer: _________________

QUESTIONS? Call Flu Busters Nursing Team at (866) 363-0955 19

INACTIVATED

VACCINEINFLUENZA

2007-08WHAT YOU NEED TO KNOW

1 Why get vaccinated? 3 Who should get inactivated
influenza vaccine?

Influenza (“flu”) is a contagious disease. People 6 months of age and older can receive inactivated
influenza vaccine. It is recommended for anyone who is at
It is caused by the influenza virus, which spreads from risk of complications from influenza or more likely to
infected persons to the nose or throat of others. require medical care:

Other illnesses can have the same symptoms and are often • All children from 6 months up to 5 years of age.
mistaken for influenza. But only an illness caused by the
influenza virus is really influenza. • Anyone 50 years of age or older.

Anyone can get influenza, but rates of infection are highest • Anyone 6 months to 18 years of age on long-term
among children. For most people, it lasts only a few days. It aspirin treatment (they could develop Reye Syndrome
can cause: if they got influenza).

· fever · sore throat · chills · fatigue • Women who will be pregnant during influenza season.

· cough · headache · muscle aches • Anyone with long-term health problems with:

Some people get much sicker. Influenza can lead to - heart disease - kidney disease
pneumonia and can be dangerous for people with heart or
breathing conditions. It can cause high fever and seizures in - lung disease - metabolic disease, such as diabetes
children. On average, 226,000 people are hospitalized every
year because of influenza and 36,000 die – mostly elderly. - asthma - anemia, and other blood disorders

Influenza vaccine can prevent influenza. • Anyone with a weakened immune system due to:
- HIV/AIDS or other diseases affecting the immune system
- long-term treatment with drugs such as steroids
- cancer treatment with x-rays or drugs

2 Inactivated Influenza vaccine • Anyone with certain muscle or nerve disorders (such
as seizure disorders or severe cerebral palsy) that can
There are two types of influenza vaccine: lead to breathing or swallowing problems.

Inactivated (killed) vaccine, or the “flu shot” is given by • Residents of nursing homes and other chronic-care
injection into the muscle. facilities.

Live, attenuated (weakened) influenza vaccine, called LAIV, Influenza vaccine is also recommended for anyone who
is sprayed into the nostrils. This vaccine is described in a lives with or cares for people at high risk for influenza-
separate Vaccine Information Statement. related complications:

For most people influenza vaccine prevents serious influenza- • Health care providers.
related illness. But it will not prevent “influenza-like”
illnesses caused by other viruses. • Household contacts and caregivers of children from
birth up to 5 years of age.
Influenza viruses are always changing. Because of this,
influenza vaccines are updated every year, and an annual • Household contacts and caregivers of people 50 years and
vaccination is recommended. Protection lasts up to a year. older, and those with medical conditions that put them at
higher risk for severe complications from influenza.
It takes up to 2 weeks for protection to develop after the
vaccination. A yearly influenza vaccination should be considered for:

Some inactivated influenza vaccine contains thimerosal, a • People who provide essential community services.
preservative that contains mercury. Some people believe
thimerosal may be related to developmental problems in • People living in dormitories or under other crowded
children. In 2004 the Institute of Medicine published a conditions, to prevent outbreaks.
report concluding that, based on scientific studies, there is
no evidence of such a relationship. If you are concerned • People at high risk of influenza complications who travel
about thimerosal, ask your doctor about thimerosal-free to the Southern hemisphere between April and September,
influenza vaccine. or to the tropics or in organized tourist groups at any time.

Influenza vaccine is also recommended for anyone who wants
to reduce the likelihood of becoming ill with influenza or
spreading influenza to others.

4 When should I get influenza Severe problems:
vaccine? • Life-threatening allergic reactions from vaccines are very

Plan to get influenza vaccine in October or November if you rare. If they do occur, it is usually within a few minutes to
can. But getting vaccinated in December, or even later, will still a few hours after the shot.
be beneficial in most years. You can get the vaccine as soon as
it is available, and for as long as illness is occurring. Influenza • In 1976, a certain type of influenza (swine flu) vaccine was
illness can occur any time from November through May. Most associated with Guillain-Barré Syndrome (GBS). Since
cases usually occur in January or February. then, flu vaccines have not been clearly linked to GBS.
However, if there is a risk of GBS from current flu
Most people need one dose of influenza vaccine each year. vaccines, it would be no more than 1 or 2 cases per million
people vaccinated. This is much lower than the risk of
Children younger than 9 years of age getting influenza severe influenza, which can be prevented by vaccination.
vaccine for the first time should get 2 doses. For inactivated
7 What if there is a severe
vaccine, these doses should be given at least 4 weeks apart. reaction?

Influenza vaccine may be given at the same time as other What should I look for?
vaccines, including pneumococcal vaccine. Any unusual condition, such as a high fever or behavior
changes. Signs of a serious allergic reaction can include
Some people should talk with a difficulty breathing, hoarseness or wheezing, hives,
paleness, weakness, a fast heart beat or dizziness.
5 doctor before getting influenza
What should I do?
vaccine Call a doctor, or get the person to a doctor right away.

Some people should not get inactivated influenza vaccine or • Tell your doctor what happened, the date and time it
should wait before getting it. happened, and when the vaccination was given.

• Tell your doctor if you have any severe (life-threatening) • Ask your doctor, nurse, or health department to report
allergies. Allergic reactions to influenza vaccine are rare. the reaction by filing a Vaccine Adverse Event Reporting
System (VAERS) form.
- Influenza vaccine virus is grown in eggs. People with a
severe egg allergy should not get the vaccine. Or you can file this report through the VAERS web site at
www.vaers.hhs.gov, or by calling 1-800-822-7967.
- A severe allergy to any vaccine component is also a
reason to not get the vaccine. VAERS does not provide medical advice.

- If you have had a severe reaction after a previous dose of 8 The National Vaccine Injury
influenza vaccine, tell your doctor. Compensation Program

• Tell your doctor if you ever had Guillain-Barré Syndrome In the event that you or your child has a serious reaction to a
(a severe paralytic illness, also called GBS). You may be vaccine, a federal program has been created to help pay for
able to get the vaccine, but your doctor should help you the care of those who have been harmed.
make the decision.
For details about the National Vaccine Injury Compensation
• People who are moderately or severely ill should usually Program, call 1-800-338-2382 or visit their website at
wait until they recover before getting flu vaccine. If you www.hrsa.gov/vaccinecompensation.
are ill, talk to your doctor or nurse about whether to
reschedule the vaccination. People with a mild illness
can usually get the vaccine.

6 What are the risks from 9 How can I learn more?
inactivated influenza vaccine?
• Ask your immunization provider. They can give you the vaccine
A vaccine, like any medicine, could possibly cause serious package insert or suggest other sources of information.
problems, such as severe allergic reactions. The risk of a
vaccine causing serious harm, or death, is extremely small. • Call your local or state health department.

Serious problems from influenza vaccine are very rare. The • Contact the Centers for Disease Control and Prevention (CDC):
viruses in inactivated influenza vaccine have been killed, so - Call 1-800-232-4636 (1-800-CDC-INFO)
you cannot get influenza from the vaccine. - Visit CDC’s website at www.cdc.gov/flu

Mild problems:
• soreness, redness, or swelling where the shot was given
• fever • aches
If these problems occur, they usually begin soon after the
shot and last 1-2 days.

Vaccine Information Statement department of health and human services
Centers for Disease Control and Prevention
Inactivated Influenza Vaccine (7/16/07) 42 U.S.C. §300aa-26