Vaccine Availability Sign-Up List (FINAL)

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EUA

I have read and understood the information in the EUA fact sheet

Vaccine Consent

I have read or have had explained to me the information provided in the Emergency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me.
Signature

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Paper Consent

Paper Consent
Consent date

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Date

FOR CLINICIAN USE ONLY DOSE 1
USE 1 INCH NEEDLE

USED 1 INCH NEEDLE
USE 1.5 INCH NEEDLE

USED 1.5 INCH NEEDLE
Lot #
Manufacturer
Expiration

Month Day Year
Date
Route
Site
Vaccinating Clinician
Vaccinating Date

Month Day Year
Date
Clinician Signature

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FOR CLINICIAN USE ONLY DOSE 2
USE 1 INCH NEEDLE (Dose 2)

USED 1 INCH NEEDLE
USE 1.5 INCH NEEDLE (Dose 2)

USED 1.5 INCH NEEDLE
Lot # (Dose 2)
Manufacturer (Dose 2)
Expiration (Dose 2)

Month Day Year
Date
Route (Dose 2)
Site (Dose 2)
Vaccinating Clinician (Dose 2)
Vaccinating Date (Dose 2)

Month Day Year
Date
Clinician Signature (Dose 2)

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