Result of capacity assessment. Name:………………………………………………….HAS/DOES NOT HAVE capacity to decide to have a Flu Vaccination, The capacity assessment is recorded in …….…………………………………………………………………………….. If capacitated, return to Section 1, if not and no LPA for personal welfare, proceed to Section 4. Section 4. If the individual lacks capacity, a best interest decision needs to be made. Decision from Best Interests meeting It is agreed that (name) ………………………………………… will receive/not receive the Flu vaccination The best interests meeting record can be found in……………………………………………………………………. Any uncertainties regarding capacity and consent can be discussed with the Local Authority MCA and DoLS Team on 01296 382195 For more guidance on capacity assessments see For a range of information on the Mental Capacity Act see Written by: Vikki Gray, Safeguarding Manager, Buckinghamshire CCGs Developed by: Reviewed by: Jacqui Kent, Care Homes Pharmacist & Tania Aitcheson, Safeguarding Lead Buckinghamshire (August 2017) Version 4 Medicines Management Sub-Committee, Aylesbury Vale and Chiltern Approved by: CCGs September 2017 Review date: August 2018
Result of capacity assessment. Name:………………………………………………….HAS/DOES NOT HAVE capacity to decide to have a Flu Vaccination, The capacity assessment is recorded in …….…………………………………………………………………………….. If capacitated, return to Section 1, if not and no LPA for personal welfare, proceed to Section 4. Section 4. If the individual lacks capacity, a best interest decision needs to be made. Decision from Best Interests meeting It is agreed that (name) ………………………………………… will receive/not receive the Flu vaccination The best interests meeting record can be found in……………………………………………………………………. Any uncertainties regarding capacity and consent can be discussed with the Local Authority MCA and DoLS Team on 01296 382195 For more guidance on capacity assessments see For a range of information on the Mental Capacity Act see Developed by: Written by: Vikki Gray, Safeguarding Manager, Buckinghamshire CCGs Reviewed by: Jacqui Kent, Care Homes Pharmacist & Tania Aitcheson, Safeguarding Lead Buckinghamshire (August 2017) Approved by: Version 4 Medicines Management Sub-Committee, Aylesbury Vale and Chiltern CCGs September 2017 Review date: August 2018
flu-consent-form-2017.docx