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Flu Shot Administration Form 2003
Public Health “Notice of
Privacy Practices.”
Signature: __________________________________________________________________________________________________
OFFICE USE ONLY
Date of Vaccine and VIS Given
Vaccine Given
Type and Date of VIS
Manufacturer and Lot Number
Influenza
Clinic Site
Site of Injection
LA
RA
Route
LT
RT
IM
SQ
Signature of Nurse
Income Assessment:
Medicaid Y____ N____ American Indian/Alaskan Native Y____ N____ Insurance Y____ N____
Annual Income...
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