fd-960 032010.pdf

FD-960

Revised

03-08-2010

FEDERAL BUREAU OF INVESTIGATION

GENERAL VACCINE CONSENT FORM

I consent to vaccination with the following vaccines (please check all that apply):

G Polio G MMR (measles mumps rubella) G Hepatitis A

G Typhoid G Td (tetanus-diphtheria) Tdap G Hepatitis B

G Meningitis G Yellow Fever G Hepatitis A & B (Twinrix)

G Anthrax G Rabies

Other (please specify): __________________________________________________________________

Please answer the following questions:

1. Do you have any allergies? G Yes G No

If yes, what? ____________________________________________________________________________

2. Are you pregnant? G Yes G No

3. Are you sick/ill now? G Yes G No

4. Have you ever had Guillain-Barre Syndrome? G Yes G No

5. Any side effect from previous injections/immunizations? G Yes G No

If yes, what? _________________________________________________________________

6. Vaccine Information Sheet(s) (VIS) given? G Yes G No

I have read the Vaccine Information Sheet (VIS) and have had an opportunity to discuss the associated risks with Health Care Programs Unit personnel. Accordingly, I request that the vaccine be given to me, and give my consent with my signature below.

Printed Name Signature of Employee Date

Last Name First Name MI Employee ID#

Division Section Extension Birth Date

Vaccine

Site Given

Lot #

VIS Date

Signature of Health Care Provider

Date