Informed Consent/Parental Permission Form - Vaccination [DEMO]
Introduction
Background
You are being offered VIGIV because you/your child:
- May have or have been exposed to a poxvirus (such as monkeypox [mpox]) and have infection or may be at risk of developing infection, including a serious or life-threatening disease.
OR
- May have or have been exposed to vaccinia (the virus in one of the smallpox vaccines that contains live virus) through getting the vaccine, contact with another person who got the vaccine, because of the work you do, or contact with a person or animal sick with orthopoxvirus, and have developed or are at high risk of having a serious reaction. This program is sponsored by the Centers for Disease Control and Prevention (CDC). This form provides information about VIGIV before you decide to receive it.
What are Poxyviruses?
Poxviruses are a family of viruses that can cause serious diseases such as smallpox or mpox. Poxviruses also include vaccinia virus, which is mostly caused by exposure to a certain type of smallpox vaccine called ACAM2000. Poxviruses may cause the following symptoms:
- Severe rash that can leave scars when healed
- Severe headaches
- High fever
- Backache and/or muscle aches
- Chills
- Swollen glands (lymph nodes)
- Tiredness
The illness typically starts with a fever and other symptoms before the rash begins. However, the rash may begin without other symptoms. The rash looks like raised bumps and pus-filled blisters (called lesions). They usually crust, scab, and fall off after about 2-4 weeks, leaving a pitted scar.
Some people who get ACAM2000 or come in contact with a person who got the vaccine may develop serious reactions such as spread of the vaccinia virus (the virus used in ACAM2000 vaccine) to other parts of the body or serious reaction at the injection site. These conditions may require treatment with VIGIV.