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For Elders & Families
Resident Family Pneumonia Vaccine Consent Form
Nazareth Home Campus
Clifton
Highlands
Anyone 65 years of age or older, or who has chronic health problems, is considered high risk for exposure to and complications from pneumococcal infections such as pneumonia, septicemia, and meningitis. The CDC currently recommends a single dose of both pneumonia vaccines for people 65 years and older who have not been previously vaccinated or whose vaccination status is unknown. One-time revaccination with both vaccines is recommended for persons 65 years and older when their last vaccination was given when they were younger than 65 years of age and it has been 5 or more years since their last dose.
Resident Name
*
First
Last
Resident Date of Birth
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MM slash DD slash YYYY
(mm/dd/yyyy)
Room Number
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Pneumococcal 13 vaccine
The Pneumococcal Conjugant Vaccine is effective against additional 13 pneumococcal types which will cause 90% of all pneumococcal pneumonia.
YES – I wish to receive pneumococcal 13 vaccine according to the recommended schedule. (This vaccine is offered annually.)
*
Yes
No
Reasons for declining.
Already Received
Select
Date Received
MM slash DD slash YYYY
Alergic
Select
Comments
Other
Select
Comments
Pneumococcal 23 vaccine
The Pneumococcal Polysaccharide Vaccine is effective against 23 pneumococcal types which will cause 90% of all pneumococcal pneumonia.
YES – I wish to receive pneumococcal 23 vaccine according to the recommended schedule. (This vaccine is offered annually.)
*
Yes
No
Reasons for declining.
Already Received
Select
Date Received
MM slash DD slash YYYY
Alergic
Select
Comments
Other
Select
Comments
I have read the CDC informational handout, have been given the opportunity to ask questions, and understand the pneumonia information provided. This facility and its employees will not be held responsible for any adverse reactions to this vaccine now or in the following years. Local site reactions are expected in 5-10% of vaccine recipients. Less than 1% of vaccines have reported slight elevations of body temperature but severe allergic reactions have not been documented.
CDC Pneumonia PCV13 Shot Information Sheet
CDC Pneumonia PPSV23 Shot Information Sheet
Signature
Date
MM slash DD slash YYYY
Responsible Party
First
Last
X
