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Standing Order Form: Influenza & Pneumococcal Vaccines

Standing Order Form: Influenza & Pneumococcal Vaccines

This standing order authorizes our company’s licensed healthcare professionals (e.g., physicians, licensed nurses,
etc.) to administer influenza and pneumococcal vaccines to patients, staff members, and volunteer workers
without the need for an individual physician evaluation or order.

1. Assessment and Evaluation:
Prior to administering the influenza or pneumococcal vaccine(s), an assessment and evaluation for
indications and contraindications will be conducted by a licensed healthcare professional. The completed,
dated, and signed copy of the assessment and evaluation form will be filed in the individual’s medical
2. Eligible Individuals:
Patients, staff members, and volunteer workers are eligible for vaccination if they meet the criteria outlined
in our company’s authorized assessment and evaluation form and have no contraindications to vaccination.
3. Informed Consent:
Individuals receiving the influenza and/or pneumococcal vaccines are required to sign an informed consent
record. In addition and prior to the administration of the influenza or pneumococcal vaccination, the
individual receiving the immunization, or his/her legal guardian, will be provided with a copy of CDC’s
current Vaccine Information Statements (VIS) relative to such vaccines. Vaccine information statements
will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine
recipients in understanding the benefits and potential side effects of such vaccines.
4. Vaccine Administration:
Only a licensed healthcare professional may administer the influenza and/or pneumococcal vaccines.
Vaccines will be administered by injection in accordance with the labeling of the vial of vaccine. Persons
receiving the vaccine(s) will be observed for reactions for fifteen (15) minutes following the administration
of the vaccine(s).

Duration of Standing Order

This standing order for the influenza and pneumococcal vaccination is effective on this the ______ day of
_____________, 20_____, and shall expire on the ______ day of ____________________, 20_____.

Signature of Authorizing Physician/Licensed Healthcare Professional

______________________ _____________________________________________
Date Signature – Physician/Licensed Healthcare Professional

______________________ _____________________________________________
License # Printed Name – Physician/Licensed Healthcare Professional

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