JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
MEASLES & RUBELLA (MR) VACCINE SCREENING & CONSENT FORM.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
FIRST NAME
*
Your answer
LAST NAME
*
Your answer
CHOOSE YOUR CLASS
*
Choose
LN
UN
KG
I
II
III
IV
V
VI
VII
VIII
IX
X
ENTER YOUR SCHOOL ID NUMBER
*
School ID Number xxx/xxxx
Your answer
MOBILE NO.
*
Your answer
DATE OF BIRTH (MONTH/DAY/YEAR)
*
Your answer
AGE IN YEARS
*
Your answer
GENDER
*
Choose
MALE
FEMALE
•
I certify that the student's age group is betwwen 9 monts to less then 15 years (b) I am the parent or legal guardian of the student. authorized to consent for vaccination for the student named above. Further, I hereby give my consent to the Department of Health and Family Welfare, Govt. of West Bengal or their agents to administer the Measles & Rubella vaccine.•I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation and possibly up to 30 minutes if medical provider deems necessary.
I voluntarily elect to receive the Measles & Rubella vaccination at Rose Bud School, Liluah after carefully considering the risks and benefits.•
•I understand that the Measles & Rubella vaccinations given at Rose Bud School will be tracked and reported to Bally Municipality Health Department, and as otherwise required by the local, state and Central government Authorities.
*
I AGREE
I ACKNOWLEDGE TO TAKE THE VACCINE (YES/NO)
*
Choose
YES
NO
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
