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Spanish H1N1 Vaccine Consent Form


This one-page Word document is a Spanish consent form that was used by the Knox County Health Department for school-located H1N1 vaccination clinics.  The form instructs parents to return the form to school if they wish their child to receive the live attenuated influenza vaccine (LAIV) FluMist.  Standard personal information and medical history are collected about the student.

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

Primary Toolkit:

Influenza Toolkit

Secondary Toolkits:

Immunization Toolkit

Keyword Area:

Cultural Competency, Immunization, Pandemic Influenza, School


Institutional Author:

Knox County 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.