H1N1 Pre-Registration

Step 1 of 3: Enter Your Information

Instructions:
Enter the information below for the person to be vaccinated. After the information is entered and the questions are answered, click the OK button to save and print your form. After you print the form in step 3, you will be able to enter another person to be vaccinated.

H1N1 Pre-Registration Form

Last Name:
First Name:
Middle Name:
Birth Date:	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905
Sex:	Male Female
Address:
City:
State:	-- Select One -- AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code:	ex. 44705
Phone:	ex. 3305551234

NOTE: Bold fields above are required.

Answer ALL of the following questions:

Is the person being vaccinated pregnant?	Yes	No
Does the person being vaccinated provide direct patient care?	Yes	No
Does the person being vaccinated care for children younger than 6 months old?	Yes	No
Does the person being vaccinated have a fever?	Yes	No
Has the person being vaccinated had a severe reaction to any medication or vaccines? Or, ever had an allergy to eggs, gentamicin, arginine, streptomycin, neomycin, polymixin B, thimerosal, gelatin, or latex?	Yes	No
Has the person being vaccinated ever had Guillain-Barre syndrome?	Yes	No
Has the person being vaccinated received any vaccine in the past 30 days?	Yes	No
Does the person being vaccinated have any of the following: asthma, diabetes, or disease of the lungs, heart, kidneys, liver, nerves, or blood?	Yes	No
Is the person being vaccinated a child that is on long-term aspirin or aspirin-containing therapy?	Yes	No
Does the person being vaccinated have a weakened immune system?	Yes	No
Does the person being vaccinated have close contact with a person who needs care in a protected environment (i.e. recent bone marrow transplant)?	Yes	No
If the person receiving the vaccination is 9 years of age or younger, is this their SECOND dose of the H1N1 vaccine? If Yes, when was first dose? (MM/DD/YYYY)	Yes	No
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