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H1N1 Parent/Guardian Letters and Consent Forms for School-located Vaccination


This tool is a 3-page PDF document developed by the Kanawha-Charlston Health Department.

The tool provides an example of informational letters and a consent form for school-located H1N1 vaccination clinics.

Kanawha-Charlston Health Department sent these forms home to the parents/guardians of school-age children during their school-located H1N1 vaccination efforts.  The H1N1 Vaccine Information Sheet (VIS) for the Live Attenuated Nasal Spray (LAIV) and the Inactivated Flu Shot were also included with this information.
Kanawha-Charleston Health Department was featured as a "Story from the Field" during a Mass Vaccination Clinic Planning Call. The health department credits these letters among the efforts that have led to numerous successful school-located vaccination clinics.

Primary Toolkit:

Influenza Toolkit

Keyword Area:

Child, Immunization, Infectious Diseases, Pandemic Influenza, School


Institutional Author:

Kanawha-Charleston Health Department




The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.