COVID-19 VACCINE SCREENING AND CONSENT FORM
SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT)
Name
First Name
Middle Initial
Last Name
UTSA ID (abc123)
Date of Birth
Age in Years
Sex (Gender assigned at birth)
Male
Female
Month
Day
Year
Race
American Indian or Alaska Native
Native Hawaiian or Other
Other Asian
Other
Hispanic or Latino
Asian
Pacific Islander
Other Nonwhite
Not Hispanic or Latino
Black or African American
White
Other Pacific Islander
Unknown
Address
City
State
Zip Code
Cell Phone Number
Format: (000) 000-0000.
Is this the patient’s first or second dose of the COVID-19 vaccination?
First Dose
Second Dose
SECTION 2: COVID-19 SCREENING QUESTIONS
1. Are you feeling sick today?
yes
no
2. Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?
yes
no
3.Do you carry an Epi-pen for emergency treatment of anaphylaxis?
yes
no
4.For women, are you pregnant or is there a chance you could become pregnant?
yes
no
5.For women, are you breastfeeding?
yes
no
6.Have you had any other vaccinations in the previous 14 days?
yes
no
7.In the past 90 days, have your received monoclonal antibodies or been diagnosed with COVID-19?
yes
no
8.Have you had, in the last 10 days, fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?
yes
no
SECTION 3: IMMUNIZATION SCREENING GUIDANCE FOR COVID-19 VACCINE
9.Do you have allergies or reactions to any medications, foods, vaccines, or latex? Please explain
yes
no
Please explain
10. Are you immunocompromised or on a medicine that affects your immune system?
yes
no
11. Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
yes
no
Moderna Covid-19 vaccine
Pfizer-BioNTech Covid-19 vaccine
12. Have you received a previous dose of any Covid-19 vaccine? If yes, please indicate which manufacturer's vaccine you received and a date the dose was administered:
yes
no
Moderna Covid-19 vaccine
Pfizer-BioNTech Covid-19 vaccine
Date administered
13.Did you experience a non-severe allergic reaction within 4 hours of a previous dose of COVID-19 vaccine? Non-severe allergic reactions can include: hives, swelling, redness, wheezing, GI symptoms, etc)? If yes, please explain
yes
no
COVID-19 (01/2021)
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm
that the patient is at least 16 years of age; or (c) authorized to consent for vaccination for the patient named above.
Further, I hereby give my consent to the
Missouri/Texas
Department of S
tate Health Services
or
FastTrack
Testing
or
their agents
to administer the COVID-19
vaccine.
I understand that this product ha
s
been approved or licensed by FDA, has been authorized for emergency use by
FDA,
under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older; and
the
emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying
the
authorization of emergency use of the medical product under Section 564(b
1) of the FD&C Act unless the
declaration is terminated or authorization revoked sooner.
I understand that i
t is not possible to predict all
possi
ble side effects or complications associated with receiving
vaccine(s
I understand the risks and benefits associated with the above vaccine and have received, read and/or had
explained to me the Emergency
Use Authorization F
act Sheet on the COVID-19 vaccine I have elected to receive. I
also
acknowledge that I
have had a chance to ask questions and that such questions were answered to my
satisfaction. I
also
understand the need for continued masking/social
distancing after receiving the COVID-19
vaccination
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. If I
experience a
severe reaction, I will
cal
l 9-1-1 or go to the nearest hospital.
I acknowledge that: (a) I understand the purposes/benefits of
ImmTrac2/
ShowmeVax
,
Texas/Missouri
i
mmunization
registry
and (b)
Mo
DSHS
will
include my personal immunization information in ImmTrac2 registry and my personal
i
mmunization
information
will be
shared with the Centers for Disease Control
(CDC) or other federal
agencies.
I acknowledge receipt of the Notice of Privacy Rights.
I voluntarily elect to receive the COVID-19 vaccination at
Fast
Track
Testing
LLC
after carefully considering the risks and
benefits.
UTSA advised me to consult with my medical provider to discuss my personal risks, benefits, and potential
side effects of
receiving the COVID-19 vaccination.
I understand that the COVID-19 vaccinations given at
Fast Track
Testing
LLC
will be tracked and reported to ImmTrac
Sh
o
wmeVax
,
and as otherwise
required by the l
ocal,
state and federal
government.
Signature of Patient or Authorized Representative
Date
/
Month
/
Day
Year
Date
Print Name of Representative and Relationship to Person Receiving Vaccine
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