NEGROS ORIENTAL PROVINCIAL HOSPITAL

NORTH NATIONAL HIGHWAY, PIAPI, DUMAGUETE CITY 6200, NEGROS ORIENTAL

INFECTION PREVENTION AND CONTROL COMMITTEE

EMPLOYEE VACCINATION CONSENT FORM

Declaration:

 I have received and read the vaccine information sheets about the diseases and the vaccines, including
information on adverse reactions that I may experience as a result of receiving the vaccine.

 I fully understand both the benefits, risks and side effects of the vaccines cited.

 I have had my questions answered to my satisfaction.

 I authorize that the vaccines I have chosen be administered to me.

 I am not allergic to eggs, yeast, thimerosal, formalin or other preservatives, streptomycin or neomycin.

 I have not had a previous adverse reaction to any of the initialed vaccines

 I understand that live vaccines including MMR and Varicella should not be given to pregnant women due to
insufficient information on side effects to the baby.

 I do not have a bleeding abnormality and I am not taking anti-coagulant medication.

 I have had the opportunity to ask the pharmacist questions concerning the vaccine and the Vaccine Information
Statement, and my questions have been answered to my satisfaction.

 I have received information regarding the privacy of my medical information.

 I have answered the above questions truthfully. By answering yes, the healthcare worker may choose to not
vaccinate, or I may be at a greater risk for adverse reactions.

 I understand it is not possible to predict all possible side effects or complications associated with receiving
vaccine(s).

 I voluntarily agree and consent to be immunized by the healthcare worker.

 The Negros Oriental Provincial Hospital shall not, at any time, or to any extent allowable by applicable law, be
liable, responsible, or in any way be accountable for any loss, injury, death, or damage suffered or sustained by
me or any other person at any time in connection with, or as a result of, the administration of the Vaccine to me
by the healthcare worker.

 I have been advised to remain near the vaccination location for approximately 30-45 minutes after
administration for observation.

Vaccine Recipient’s Name: _________________________________________ Date of Birth _____/_______/______

Vaccine Recipient Legal Representative’s Name if under 18: _____________________________________________
Vaccine Recipient or Vaccine Recipient’s Legal Representative Signature: _________________________________
Date: _______________________ Time: ______________________ Witnessed by: __________________________