Vaccine Administration (Pharmacist Use ONLY)
I hereby certify that I have verified the screening questionnaire and consent with the above named patient
Vaccine: COVID-19 Vaccine Dose: Booster Qty: 0.25ml /0.3ml / 0.5ml Manufacture: Pfizer / Moderna
Lot Number: ________________ Expire Date:______________
Injection Site: Left Arm / Right Arm Route: IM
VIS Identification: EUA COVID-19 VACCINE Date of Publication:
Did an Adverse Reaction occur? Yes / No
Contacted VAERS 800-822-7967 Date/Time:
Primary Care Physician contacted: Yes / No
Administered By: Pharmacist Signature:
NJIIS Uploaded By: Billed to ins. By: