Smallpox pre-vaccination information packet : contents and instructions
Published Date:November 15, 2003
Corporate Authors:Centers for Disease Control and Prevention (U.S.)
Description:The following information is for state and hospital personnel implementing smallpox vaccination programs.
1. Cover Letter ñ A letter from Dr. Julie Louise Gerberding, M.D., MPH., Director of the Centers for Disease Control and Prevention (CDC) to potential vaccinees explaining the purpose of the national smallpox preparedness program, encouraging individuals to know their health status and to err on the side of caution in making their vaccination decision and detailing the contents of the Smallpox Pre-Vaccination Information Packet.
2. Smallpox Vaccine Information Statement (VIS) - This document, entitled "Smallpox Vaccine: What You Need to Know," contains information about smallpox disease, the benefits and risks of smallpox vaccine, contraindications, vaccination site care instructions, what to do if a reaction occurs after vaccination, and where to get more information.
3. Pre-Event Screening Worksheet for Smallpox Vaccine ñ a worksheet with questions to help individuals determine whether or not they should receive smallpox vaccine because of certain medical conditions that would place them at a greater risk for an adverse reaction from the vaccine. Some of these questions are of a personal and sensitive nature. Those implementing smallpox vaccination clinics should be prepared to discuss, but not collect, this sheet.
4. Someone You are Close to May Get Smallpox Vaccine: What You Should Know and Do - a fact sheet that informs close contacts of people considering vaccination about the health conditions that put people at risk if they are in close physical contact with someone who has been vaccinated. This sheet also provides information about the steps close contacts can take to protect themselves.
5. Smallpox Vaccine: Decision Point for the Smallpox Vaccine Candidate - a short video intended as an overview for use at vaccination clinic sites to supplement the written materials listed above.
6. Patient Medical History and Consent Form - a form for clinic personnel to record patient information. The form also confirms the absence of contraindications and contains a consent signature line for the patients. This document must be retained by the clinic for 5 years or the length of time required by state law, whichever is longer.
7. Temporary Proof of Vaccination and Site Check Reminder Sheet - This form serves as temporary proof of vaccination, contains follow-up appointment information, and provides vaccine recipients with a phone number to call if they think they are having an adverse reaction to the vaccine.
Instruction for Use
This package of materials is to be used as part of the national smallpox preparedness program to help ensure that potential vaccinees are adequately informed of the benefits and risks of smallpox vaccination, to assist in screening out individuals who should not receive the vaccine, and to obtain signed consent from those individuals who receive smallpox vaccine. In particular circumstances as provided by law, the federal government may assume liability for injury or death attributable to a smallpox vaccination. The materials contained in this packet fulfill federal obligations to inform vaccinees about the risks and benefits of the smallpox vaccine. Use of the items in this packet as instructed below is mandatory. Do NOT alter the materials or replace them with alternative documents.
Supporting Files:No Additional Files
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