2009 Seasonal & H1N1 Influenza and Pneumococcal OSIIS Data Entry Form

Last Name

First Name

Middle Initial

Date of Birth __ __ - __ __ - __ __ __ __

Street Address

City

State

Zip

Gender Male o Female o

Ethnicity Hispanic Origin Yes o No o

Phone Number ( ) _______ - ___________

Race White o Black/African American o Asian o American Indian/Alaskan Native o Native Hawaiian/Other Pacific Islander o

Needed for children under age 18 only only Mother’s Maiden Name

Medicaid Number

Medicaid Last Name

Medicaid First Name

Medicare Number (Include letter) ______________________________

Medicare Part B Yes o No o

PLEASE ANSWER THE FOLLOWING QUESTIONS: 1. Is the person to be vaccinated sick today? Yes o No o Don’t Know o 2. Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine? Yes o No o Don’t Know o 3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? Yes o No o Don’t Know o

For Clinic Use Only – Do Not Write Below This Line

VFC Status:

0 – Not Eligible o 1 – Medicaid o 2 – Native America o 3 – Native Alaskan o 4 – Underinsured o 5 – No Insurance o 6 – Private Insurance o

Date Given

Include Dose # for children under 10 years of age

Given By (Initials)

Vaccine Name in OSIIS

Lot Number Dose (Circle Correct #) 1 or 2

Given By (Initials)

Vaccine Name In OSIIS

Lot Number Dose (Circle Correct #) 1 or 2

Seasonal Vaccines

H1N1 Vaccines

Trivalent Flu 6-35m

U3260AA

H1N1 San 6-35m

Trivalent Flu 3-18y

U3253AA U3259EA

H1N1 San 6 m-older

Trivalent Flu (VFC)

U3210AA

H1N1 San 3-older

Tri Flu Fluzone

U3195AA

H1N1 Nov 4–older

Tri Flu VFC-Fluvirin

H1N1 CSL 18y-older

Tri Flu Fluvirin

98437P1A

H1N1 Med Nasal Mist

Tri-Flu Nasal Mist

500697P 500709P

Tri Flu Fluarix

Tri Flu FluLaval