Fast Track H1N1 Vaccine Consent Form
Author: Knox County Health Department
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Fast Track H1 N1 Vaccine Consent Form 1 id1925
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This 2-page consent form was used for a fast track H1N1 only clinic outside Knox County Health Department's usual clinic location. The form collects standard personal information and medical history from the patient. On the second page, the health care provider submits vaccine and site administration data. This tool was submitted as part of an H1N1 Story from the Field. The story can be found at this link: http://www.naccho.org/topics/H1N1/h1n1story.cfm?story_id=293
Program: Community Health
Submitted Date: Feb 03, 2010 | Modified Date: Sep 30, 2025
Primary Toolkit: Influenza Toolkit | Secondary Toolkit: Influenza Toolkit
Jurisdiction:
Institution Type: LHD - County,
Keywords: Influenza, Immunization
