Get Client Screening Questionnaire And Acknowledgement Form For - Nationalservice

Filling out the client screening questionnaire and acknowledgement form for nationalservice is an essential step in ensuring your protection against influenza. This guide provides clear, step-by-step instructions to help you complete the form accurately and confidently.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to access the client screening questionnaire and acknowledgement form. This will allow you to open the document in an online editor.
2. Begin by completing Part 1: Employee Information. Fill in your full name, including last and first names. Provide the last four digits of your Social Security number, your date of birth, work address, work phone number, and work email address.
3. In the same section, indicate any known allergies, whether drug or food-related. If you are taking any medications, list them clearly in the provided space.
4. Sign the form to acknowledge your understanding of the benefits and risks associated with the influenza vaccine. Ensure that your signature is dated and legible.
5. Review the Privacy Act Notice contained within the form to understand how your information will be used and protected.
6. Upon completing the first part of the form, follow any additional instructions or complete Part 2, which may require input from a clinician regarding the influenza vaccination record, if applicable.
7. After finishing the form, save your changes. You can also download, print, or share the form as necessary.

Take action now and complete the client screening questionnaire and acknowledgement form online for flu vaccination.