TITLE: GUIDELINE FOR INFANT VACCINE CONSENT AND ADMINISTRATION FORM

 KEYPOINTS:  Vaccine administration to an infant should be consented by a parent or guardian.  Instructions must be provided and explained by an RN.  The Vaccine Information Statement (VIS) is an information sheet, produced by the Centers for Disease Control and Prevention (CDC), informing vaccine recipient - or their parents or legal representatives - of the benefits and risks of a vaccine.  The law requires them to be given out whenever certain vaccinations are given.  Provision of the VIS is a requirement of the National Childhood Vaccine Injury Act of 1986.  It's purpose is to inform parents and others of the benefits and risks of vaccines.

VICs must be given at the time of each vaccination - prior to administration of the vaccine.

As of September 2001, VISs that must be used are: diphtheria/ tetanus/ pertussis (DtaP),  tetanus (Td), polio (IPV), hepatitis B, haemophilus influenza type b (Hib), and pneumococcal conjugate.

The most current VIS can be obtained on Adobe/Hosp H drive.

INSTRUCTIONS:

1. Write in the Hep B VIS number printed on the bottom of the VIS form.
2. Parent/Guardian will sign the consent and note the date.
3. The RN or MD obtaining the consent will provide the VIS, explain the information, answer the parent' questions, and sign as witness and date the form.
4. When HBIG is administered, place an X in the area, the RN/LPN who administers the HBIG injection will sign and date.
5. When the Initial Hepatitis HB-1 is administered, place an X in the area, the RN/LPN who administers the HB-1 injection will sign and date.
6. If a repeat Hepatitis HB-1 injection is ordered, the RN/LPN administering the injection will mark the area, sign and date.  The original Hepatitis consent (above) also covers the postnatal immunizations for Hepatitis immunizations.
7. When Two Month Immunizations are ordered, the RN/MD obtaining the consent will provide VIS, explain the information, answer the patient's/parents' questions,  sign as witness, and date the form.  The VIS number for each applicable consented immunization must be noted in the appropriate blank.
8. When IPV is administered, the RN/LPN who administers the IPV injection will sign and date.
9. When the DtaP is administered, the RN/LPN who administers the DTaP injection will sign and date.
10. When the HB-2 (Hepatitis B 2 month) is administered, the RN/LPN who administers the HB-2 injection will sign and date.
11. When the HBV (HIB or Haemophilus influenza b) is administered, the RN/LPN who administers the HBV injection will sign and date.
12. When the Prevnar (Pneumococcal) is administered, the RN/LPN who administers the Prevnar injection will sign and date.

KEYPOINT:  Should the parent refuse immunizations, the RN/MD must provide and complete a MR ## Patient's Release Upon Refusal of Treatment Form.  This form should be attached to the immunization consent form.  The RN/MD should note parent's refusal on top border of Vaccine Administration Record and Request Form.

RESOURCE PERSON(S):  Shannon Lewis, BSN, RN; Martha Rabaduex, BSN, RN

Infant Vaccine Consent and Administration Form

Newborn Immunizations

 “I have been given a copy and have read or have had explained to me the information on this form about hepatitis b, hepatitis B immune globulin, and hepatitis B vaccine.  I have had a chance to ask questions which were answered to my satisfaction.  I believe I understand the benefits and risks of hepatitis B immune globulin and the hepatitis B vaccine and request that these be given to me or the person named above for whom I am authorized to make this request.”                                                                                       

Hepatitis B Information Statement # ___________.

Signature of person to receive vaccine or person authorized to make the request (parent or guardian):

X_______________________________________Date: __________  Witness:  _____________________ Date:  __________

 ____HBIG (Hepatitis Immune Globulin) Administered by:______________________________________ Date:  __________

____Initial HB-1 (Hepatitis vaccine)          Administered by: _____________________________________  Date: __________

Post Natal Immunizations 

____Repeat HB-1 (Hepatitis vaccine for those infants born under 2000 grams at birth that received an initial newborn HB-1)

 Administered by:_______________________________________________________________         Date: __________

“I have been given copies and have read or have had explained to me the information on this form about  polio and polio vaccines; diphtheria, tetanus (lockjaw) and pertussis (whooping cough) disease and DTAP vaccines; Hepatitis b and hepatitis b vaccines; Haemophilus Influenzae Type b vaccine; Pneumococcal Conjugate vaccine (Prevnar).  I have had a chance to ask questions which were answered to my satisfaction.  I believe I understand the benefits and risks of the vaccine and request that these be given to me or the person named above for whom I am authorized to make this request. 

IPV

information statement # ______________         Administered by: _____________________________Date:  ___________ 

DTAP

Information statement # _______________       Administered by:  ____________________________Date: ____________ 

HB-2

 information statement # _______________       Administered by:  ____________________________Date:  ___________ 

HBV (HIB)

 information  statement # ________________  Administered by: _____________________________ Date: _____________ 

Prevnar 

information statement # ________________   Administered by:   _____________________________Date:  ____________ 

Signature of person to receive vaccine or person authorized to make the request (parent or guardian): 

X____________________________Date:  __________________ Witness:  _____________________Date:  __________

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