COVID-19 VACCINE CONSENT FORM

Prevaccination Checklist for COVID-19 Vaccination

Name:

For vaccine recipients (both children and adults):

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 as the healthcare provider to explain it.

1. How old is the person to be vaccinated?

2. Is the person to be vaccinated sick today?

Yes

Don't know

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

Yes

Don't know

If yes, which vaccine product was administered?

4. Is the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised?

Yes

Don't know

5. Is the person to be vaccinated received COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies?

Yes

Don't know

Has the person to be vaccinated ever had an allergic reaction to (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)

• A component of a COVID-19 vaccine

Yes

Don't know

• A previous dose of COVID-19 vaccine

Yes

Don't know

7. Has the person to be vaccinated ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)

Yes

Don't know

8. Check all that apply to the person to be vaccinated:

Have a history of myocarditis or pericarditis

Have a history of Multisystem Inflammatory Syndrome (MIS-C or MIS-A)

Have a history of an immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia (HIT)

Have a history of thrombosis with thrombocytopenia syndrome (TTS)

Have a history of Guillain-Barré Syndrome (GBS)

Have a history of COVID-19 disease within the past 3 months

Vaccinated with monkeypox vaccine in the last 4 weeks

Covid 19 Form