Department

COVID-19 Immunization Screening and Consent Form*

W - Widowed V - Civil Union U - Unknown

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

AIA - Native American or Alaskan

BAA - African American or Black

NHP - Native Hawaiian or Pacific Islander

In the last 10 days, have you had a COVID-19 test or beentold by a healthcare

provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?

Have you been treated with antibody therapy for COVID-19 in the past 90 days (3 months)?

If yes, when did you receive the last dose?

Have you ever had a serious or life-threatening allergic reaction, such as hives or difficulty breathing, to any vaccine or shot?

Have you had any vaccines in the past 14 days (2 weeks) including flu shot+? If yes, how long ago was your most recent vaccine?

Are you pregnant or considering becoming pregnant?

Do you have cancer, leukemia, HIV/AIDS, a history of autoimmune disease or any other condition that weakens the immune system?

Do you take any medications that affect your immune system, such as cortisone,

prednisone or other steroids, anticancer drugs, or have youhad any radiation

hasthe TheFDAmadeavailableunderan COVID-19vaccine

authorization(EUATheEUAisusedwhencircumstancesexistto

justify the emergency use of drugs and biological products duringan emergency, sucha as the COVID-19 pandemic. This vaccine has not completed the same type of review as an FDA-approved or cleared product. However, the FDA's decision to make the vaccine available under an EUA is based on the existence of a public health emergency and the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.

I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if this vaccine requires two doses, two doses of this vaccine will need to be administered (given) in order for it to be effective. I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions) I understand the benefits and risks of

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administeringthe vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health insurance plan, Medicare, Medicaid or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as neededfor other public health purposes, including reporting to applicable vaccine registries.

Area Below to be Completed by Vaccinator

Which vaccine is the patient receiving today?

* Use of this form is optional.