Form DOH348-054 "Influenza Vaccine Administration Request" - Washington

What Is Form DOH348-054?

This is a legal form that was released by the Washington State Department of Health - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 5, 2007;
  • The latest edition provided by the Washington State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH348-054 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download Form DOH348-054 "Influenza Vaccine Administration Request" - Washington

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INFLUENZA
INFLUENZA VACCINE
ADMINISTRATION REQUEST
"I have received the current Influenza Vaccine Information Statement (VIS), describing 'What you need to know' before you
or your child gets the vaccine. I received the 20____ - 20____ VIS [provider fill in VIS year]. I have read or have had explained to
me the information in this VIS about influenza vaccine. I have had a chance to ask questions that were answered to my
satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that it be given to me or the person named
below for whom I am authorized to make this request." Sign in the appropriate row below.
Clinic
County
_
___________________________________________________________
__________________________________________________
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
1 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
2 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
3 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
4 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
5 X
_______________________________________
DATE
DOH 348-054 MSL Influenza (REV 10/5/07)
INFLUENZA
INFLUENZA VACCINE
ADMINISTRATION REQUEST
"I have received the current Influenza Vaccine Information Statement (VIS), describing 'What you need to know' before you
or your child gets the vaccine. I received the 20____ - 20____ VIS [provider fill in VIS year]. I have read or have had explained to
me the information in this VIS about influenza vaccine. I have had a chance to ask questions that were answered to my
satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that it be given to me or the person named
below for whom I am authorized to make this request." Sign in the appropriate row below.
Clinic
County
_
___________________________________________________________
__________________________________________________
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
1 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
2 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
3 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
4 X
_______________________________________
DATE
Information about person to receive vaccine (please print).
For Clinic Use Only:
NAME:
LAST
FIRST
MIDDLE INITIAL
BIRTHDATE
AGE
CLINIC / OFFICE ADDRESS: ___________________________
DATE VACCINE ADMINISTERED: _______________________
VACCINE MANUFACTURER: ___________________________
ADDRESS:
STREET
CITY
COUNTY
STATE
ZIP
VACCINE LOT NUMBER: ______________________________
SITE OF INJECTION: _________________________________
SIGNATURE OF VACCINE ADMINISTRATOR:
SIGNATURE OF PERSON TO RECEIVE OR PERSON AUTHORIZED TO MAKE THE REQUEST:
X__________________________________________________
TITLE OF VACCINE ADMINISTRATOR: ___________________
5 X
_______________________________________
DATE
DOH 348-054 MSL Influenza (REV 10/5/07)