Influenza Clinic Forms and Information Sheet

 Flu Clinic Information and Forms

The flu season is quickly approaching, and preparations have begun for school-based flu clinics.  I have attached this years’ consents for students and staff, along with the VIS (vaccine information statement) and parent letter in English and Spanish. The VIS must be given with consents. If possible, please have parents and staff attach a copy of their insurance card to the consent form.  For uninsured staff, the Health Department, does not yet have the pricing on the vaccine for this year. Last year it was $30. I will provide you with that price once I have that information. The consents must be completely filled out with a signature (Please emphasize this) in order for the Health Department to be able to administer the vaccine. Please have all consents returned to me by 2:00 pm September 7th, 2018. Therefore, your deadline for parents/staff should be no later than September 6th.  Once all the consents are received, the Health Department will work on a schedule. I will send the schedule out to you as soon as I receive it.

On the consent form, in the Date blank,  you will need to write “to be announced later”, because you do not have the date yet as to when the SBF Clinic will take place in your school(s).  After you receive the date of the Flu Clinic, get with your principal to decide how each school wants to inform parents/staff of date of Flu Clinic at your school(s).


Consent Form English


Consent Form Spanish


Information Sheet English


Information Sheet Spanish


Staff Consent Form