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Content on this page was developed during the 2009-2010 H1N1 pandemic and has not been updated.

  • The H1N1 virus that caused that pandemic is now a regular human flu virus and continues to circulate seasonally worldwide.
  • The English language content on this website is being archived for historic and reference purposes only.
  • For current, updated information on seasonal flu, including information about H1N1, see the CDC Seasonal Flu website.

School-Located H1N1 Influenza Vaccination: Template Letter to Parents to Seek Advanced Consent for Vaccination

September 13, 2009, 2:45 AM ET

Download editable Word version

STATE or LOCAL HEALTH DEPARTMENT LOGO
STATE or LOCAL HEALTH DEPARTMENT ADDRESS

DATE

Dear Parents/Guardians:

As you may have heard, a new influenza virus, called the 2009 H1N1 influenza virus, was first identified in the United States in late April 2009.  The virus has caused illness ranging from mild to severe, including hospitalizations and deaths in adults and children. Many children have gotten 2009 H1N1 infection and there have been large outbreaks in some schools across the country. The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices has recommended that children and young adults aged 6 months through 24 years be vaccinated against 2009 H1N1 as soon as the vaccine is available.  Other groups recommended to get the first doses of 2009 H1N1 influenza vaccine are: 

  • Pregnant women
  • People who live with or care for children younger than 6 months of age
  • Health care and emergency medical services workers, and
  • People ages 25 through 64 years who have certain health conditions such as HIV, diabetes, or heart or lung disease.

Vaccination is the best way to protect your child from this potentially serious disease.  The STATE/LOCAL health department is working with your child’s school to give the 2009 H1N1 influenza vaccine to children at school.  We will hold vaccination clinics beginning this fall, and your child’s school will let you know the specific dates once vaccine is on hand.  Children are expected to need two doses of vaccine spaced about 3 weeks apart.  There will be no cost to you for this vaccine.  

The vaccine consent form includes options allowing you to either accept or refuse the vaccination for your child.  If you refuse, the vaccination will not be given to your child.  There are two ways you can accept:

1) You can read the “What you need to know” form included with this letter about the disease and the vaccine.  You must then sign and date the included consent form to accept vaccination for your child and return it to the school.  If you accept vaccination, the vaccine will be given to your child when it is on hand.  School staff will let you know when the vaccination clinic will take place about [__weeks] before.  If, at any time, you change your mind about having your child vaccinated, you can [INSTRUCTIONS ON HOW TO WITHDRAW CONSENT].  Giving consent early will ensure that your child is ready to receive the vaccine as soon as it is on hand.

2) If you prefer, you can wait until school staff send you a second informational packet closer to the time when vaccinations will be offered at your child’s school.  This packet will also contain a “What you need to know” form about the disease and the vaccine as well as a consent form that you can sign and date to accept vaccination for your child.   

If you have any questions about the vaccine or the vaccination clinics, please call:  xxx-xxx-xxxx from X AM to X PM.  Please visit www.flu.gov or the CDC’s 2009 H1N1 influenza web site at www.cdc.gov/h1n1flu/. Also, please visit www.cdc.gov/h1n1flu/parents for more information especially for parents.  Your child’s health care provider also can answer your questions about the 2009 H1N1 influenza virus and will be able to give your child the seasonal influenza vaccine and may be able to give your child the 2009 H1N1 vaccine.

Sincerely,

 

State or local health department official
 
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    Atlanta, GA 30333
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