University of Florida

Smallpox Vaccine Consent Form

Name______________________________   Department ____________________________

UF ID _____________________________   Title __________________________________

Date _______________________________  Position # __________  Phone _____________

I have read the informational package concerning biosafety considerations for working with vaccinia virus and related orthopoxviruses and I have had an opportunity to ask questions about this information of both a subject expert and a health care professional.  I understand that I may obtain a smallpox vaccination administered by university medical personnel at no cost to me.

I understand that failure to consent to vaccine will prohibit me from working with any “pox” viruses.

Consent to Vaccination

I authorize and request the University of Florida and its designated employees to administer the vaccine to me.

Employee Signature  _____________________________________

Date Given ______________________Lot Number ____________

Administered By ________________________________________