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Flu Vaccination Consent Form 2024

Flu vaccination is the best way to prevent catching and spreading influenza. Mater’s 2024 flu vaccination program launches from Tuesday 16 April with a free flu shot for all Mater People—including volunteers, VMOs, Mater Education students and onsite tenants—at all campuses.

Specific points about the vaccine and other information can be found on the Frequently Asked Questions (FAQs) page.

Personal Details
As it would appear on your Medicare card
As it would appear on your Medicare card
If you do not have a Mater email address, please use the email address you provided to Mater
If you do not have a Medicare number, please use 0000000000
e.g. 12345, T12345 or E12345 (as displayed on your staff identification card)
Pre-vaccination screening
Is this the first time you have received a vaccination for influenza?
Do you have a fever or feel unwell today?
Have you ever had a severe reaction or anaphylaxis following a previous dose of any influenza vaccine?
Have you ever had a severe reaction or anaphylaxis following any vaccine component traces (formaldehyde, Octoxinil-9, sodium phosphate dibasic anhydrous, sodium phosphate monobasic anhydrous, eggs)?
Have you ever been diagnosed with Guillain-Barre Syndrome?
Do you have a bleeding disorder such as haemophilia, thrombocytopenia or on anticoagulant therapy?
Consent Acknowledgement
By completing this form, you agree to have read and understood:
● The purpose, contra-indications and possible side-effects of this vaccination.
● It is my decision to be immunised with FluQuadri/Fluad Quad vaccination.
● The vaccine is administered according to recommendations of the National Health and Medical Research Council.
● That I must remain in the vicinity for 15 minutes after the vaccination.
● My records will be uploaded to the Australian Immunisation Register for future access.
● I will not proceed with vaccination if I have had a fever or felt unwell in the previous 24 hours of my planned vaccination.
● I have read the specific points about vaccine and frequently asked questions (FAQs)
I accept the above terms

Personal information collected by Mater is handled in accordance with privacy legislation and the appropriate Mater Policies and Procedures. All personal information will be securely stored and only accessible by authorised employees within Mater. Your personal information will not be disclosed to any third parties without your consent, unless required or authorised by law.