Tulsa Regional Medical Center 
       
      <Hospital Name>
      Inpatient Pneumococcal/Influenza Immunization Order Form
        
      (Apply Patient Sticker)
      Patient:Assessed by:Date:
       
      Ś Risk Assessment:  Choose Vaccine(s) (Check all that apply)
       
      Pneumococcal Vaccine1 (offer year round)
       
      †  Vaccine indicated (if any of the following):
      Patient is:
      ·          65 years of age or older; 
      ·          Resident of nursing home or chronic care facility regardless of 
      age; OR
       
      Patient is age 19-64 and has any of the following high-risk conditions: 
      ·          Serious long-term health problem with chronic heart or lung 
      disease (including asthma), diabetes mellitus, or kidney disease including 
      nephrotic syndrome
      ·          Compromised immunity such as: Hodgkin’s disease, leukemia, 
      lymphoma, multiple myeloma, generalized malignancy, HIV infection or AIDS, 
      organ or bone marrow transplant, treatment with long-term corticosteroids, 
      cancer drugs, or radiation therapy
      ·          Alcoholism, cirrhosis, or chronic liver disease
      ·          Sickle cell anemia or prior splenectomy
      ·          Cerebrospinal fluid leaks; OR
       
      Patient uncertain about prior vaccination status or history unreliable and 
      meets the above criteria (vaccination recommended – discuss with 
physician)
       
      †  None of the above (STOP the Assessment)
       Influenza Vaccine2 (September through March)
       
      †  Vaccine indicated (if any of the following):
      Patient is:
      ·          50 years of age or older
      ·          Resident of nursing home or chronic care facility regardless of 
      age; OR
       
      Adult or child that has any of the following high-risk conditions:
      ·          Serious long-term health problem with chronic heart or lung 
      disease (including asthma), diabetes mellitus, kidney disease, or anemia 
      and other blood disorders
      ·          Compromised immunity such as: Hodgkin’s disease, leukemia, 
      lymphoma, multiple myeloma, generalized malignancy, HIV infection or AIDS, 
      organ or bone marrow transplant, treatment with long-term corticosteroids, 
      cancer drugs, or radiation therapy
      ·          Children and adolescents (aged 6 months-18 years) who are 
      receiving long-term aspirin therapy
      ·          Women who will be past the 3rd month of pregnancy during the 
      influenza season; OR
       
      Patient uncertain about prior vaccination status or history unreliable and 
      meets any of the above criteria (vaccination recommended – discuss with 
      physician)
       
       
      †  None of the above (STOP the Assessment)
      Ť Vaccination Status or Contraindications (Check all that apply)
       
      †  Pneumococcal vaccine not indicated (if any of the following):
      ·          Previously immunized after age 65
      ·          Previously immunized before age 65, but < 5 years ago
      ·          Reported allergy to vaccine
      ·          Physician order not to give vaccine this admission
      ·          Patient refuses†  Influenza vaccine not indicated (if any of 
      the following):
      ·          Previously immunized this flu season
      ·          Ever had a serious allergic reaction to eggs
      ·          Previous serious reaction to influenza vaccine
      ·          History of Guillain-Barre syndrome (discuss with physician)
      ·          Physician order not to give vaccine this admission
      ·          Patient refuses
       
      Ž Vaccination Decision (Check all that apply – both may be given at same 
      time)
       
      †  Pneumococcal vaccine indicated – no contraindications identified (Year 
      Round)
       
      Administer vaccine 0.5 cc IM deltoid
       
      Date_______________    Time ____________________
       
      Signature: _____________________________________
       †  Influenza vaccine indicated – no contraindications identified 
      (September through March)
       
      Administer vaccine 0.5 cc IM deltoid
       
      Date_______________    Time ____________________
       
      Signature: _____________________________________
       


 
1 MMWR 1997;46(No. RR-8):1-24.                                                   
                       2MMWR 2002:51(No. RR-3):1-32.