COVID 19 Vaccine Screening Form v.101623

COVID-19 Vaccine Screening and Consent Form for Children and Adults

Recipient Name (please print)*

Preferred Name

Address*

Address

Street Address Line 2

CityState

Zip

Email Address*

example@example.com

Parent/Guardian/Surrogate (if applicable, please print)

Phone*

Preferred Language

DOB*

Current Gender ID*

Write-in if Gender not Listed

Gender Pronouns (write-in)

Sex Assigned at Birth*

Marital Status*

Ethnicity*

Race*

Medical Insurance Name

Medical Insurance ID#

Subscriber Name

Subscriber DOB

Relation to Patient

Medical Insurance Address

Medical Insurance Group #

Primary Care Physician Address/Phone Number

Clinic/Office Site Where Vaccine is Administered

Primary Care Physician Address/Phone Number

Screening Questionnaire

The following questions will help us determine if there is any reason COVID-19 vaccine cannot be given today. If you answer “yes” to any question, it does not necessarily mean the vaccine cannot be given. It just means additional questions may be asked. If a question is not clear, please ask a healthcare provider to explain it.

1. Are you feeling sick today?*

2. In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due toCOVID-19 infection or exposure?*

3. How old will the person be on the day of vaccination?*

4. Has the person to be vaccinated ever received a dose of COVID-19 vaccine?*

If YES, which product was administered?

How many doses of COVID-19 vaccine were previously administered?

Did you bring the vaccination record card or other documentation?

5. Have you ever had an immediate allergic reaction (e.g., hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?*

6. Are you moderately or severely immunocompromised due to one or more of the medical conditions or receipt of immunosuppressive medications or treatments listed below?1) Active treatment for solid tumor and 2)hematologic malignancies, 3) Receipt of solid-organ transplant and taking immunosuppressive therapy, 4) Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy), 5) Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome), 6) Advanced or untreated HIV infection, 7) Active treatment with high-dose corticosteroids (i.e., 20 mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.*

7. Are you pregnant or considering becoming pregnant?*

8. Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?*

9. Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?*

10. Do you have a history of MIS-C or MIS-A (multisystem inflammatory syndrome in children or multisystem inflammatory syndrome in adults)?*

11. Have you recently received an orthopoxvirus vaccine within the last 4 weeks (e.g., JYNNEOS or ACAM2000)?*