SUBJECT RECEIVING IMMUNIZATION:
M F
ADDRESS
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Individual or Parent/Guardian Signature_____________________________________________Date:____________________
VACCINE MANUFACTURER: __________________________________________________________________
DATE Vaccine Administered: _________________________________ ROUTE: IM SITE: LD RD
COVID-19 Vaccine EUA FACT SHEET for Recipients provided. EUA DATE: _____________________
NAME/TITLE of Vaccine Administrator: _________________________________________________
LOT #:________________________________
EXP: __________________ DOSE: FIRST or SECOND
2. Had any vaccinations in the last 14 days?............................................................................................
___________________________________________________________
(_________)_________________________________________________
LEGAL Name (FIRST MI LAST)
_________________________________________________________ _____________________
600 S 4
th
St, Council Bluffs, IA 51503 - Phone 712.242.1155 - Fax 712.242.1162
Pottawattamie County Public Health
CITY STATE ZIP CODE
_______________________
_________ _______________
EMAIL ADDRESS
____________________________________________
SECTION 1: VACCINE RECIPIENT INFORMATION (PLEASE PRINT LEGIBLY)
COVID-19 IMMUNIZATION CONSENT FORM
FOR ADMINISTRATIVE USE ONLY:
SECTION 2: SCREENING FOR VACCINE ELIGIBILITY (Select YES or NO)
1. Have an allergy to latex? ……………….……………………..….………………..………………………………………….……
3. Had a serious reaction to a previous dose of any vaccine? …..…………………….…………………………..………..……..……………….
4. Have any neurological, seizures, central nervous system disorders, Guillain-Barre? ………………….….………………………….
5. Pregnant or planning to be in the next 4 weeks?...................................................................................................................
I understand the risks/benefits and request that the vaccine be given to me or the person named for whom I am authorized to make this request.
SECTION 3: CONSENT
6. Has the person listed above previously received COVID-19 Vaccine?……………………………………………...
If yes to above, indicate the COVID-19 vaccine previously received:
Vaccine Brand Administered (Pfizer, Moderna, Astra Zeneca, Johnson & Johnson)_____________________________
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 or to the person named
above for whom I am authorized to make this request.
Updated 12/16/2020
