CLEARLY TYPE or PRINT information below about the person receiving the vaccine OR CIRCLE correct responses.
Last Name ____________________________ First Name ______________________ M_________________
Birth date ______ /______ /______
Sex: F M Other
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown
Race:
American Indian/Alas
ka Native
Asian Black/African American
Hispanic or Latino
Native Hawaiian/Other Pacific Islander White Other Race/Multiracial
_
Home Address: ______________________________ City: ____________________ State: _ __
County: __________________ Phone # (______) ________________
Please answer all the questions below.
1.
Are you under 18 years of age? ……………………………………………………………………………………………………...
2. Are you pregnant or breastfeeding?.…………………………………………………………………………………….……….…. YES NO
3. YES NO
4. YES NO
5.
Have you received a vaccine in the last 14 days? ……………………………………………………
……….…………..…...
YES NO
6.
Are you experiencing moderate or severe acute illness with or without fever including any COVID
symptoms?...........................................................................................................................................
7.
YES NO
8.
Have you ever had a serious reaction to a vaccine (e.g., anaphylaxis)?...............................................
YES NO
9.
Have you ever had a serious reaction to an injectable medication (e.g., anaphylaxis)?.....................
10.
Are you allergic to any of the ingredients in the COVID vaccine?.........................................................
YES NO
11.
Have you tested positive for COVID?...................................................................................................
YES NO
YES NO
YES NO
Are you currently in quarantine or isolation?........................................................................................
NOTE: Please continue to protect yourself and others from COVID-19 with good hand washing, wearing a mask, maintaining
social distance of at least 6 feet from others, and staying home when you are ill.
CONSENT
I have been given and read the Emergency Use Authorization (EUA) for the Moderna Vaccine and have had my
questions answered about COVID-19 vaccine. I understand the benefits and the risks of the COVID-19 vaccine and ask
that the vaccine be given to me. Moderna requires 2 doses, 28 days or more apart, to be fully effective. I agree to
obtain the second dose.
Signature____________________________________________ Date_____/_____/______
FOR ADMINISTRATIVE USE ONLY
Clinic Site:
____________________
Administration Date
(Circle Month/Enter Day)
VaccineManufacturer
Vaccine Administrator
Signature Title (circle one)
Route
IM
Dose
Administered
R deltoid
L deltoid
0.5 mL
Information entered into I-CARE: Initials_______ Date ______________
KANE COUNTY HEALTH DEPARTMENT
CONSENT FORM AND ADMINISTRATION RECORD
MODERNA SARS-CoV-2 Vaccine (COVID-19) 2020-2021
IL
Kane County Fairgrounds
cr. 01/07/20
rv #6_01/28/21
(Circle)
Have you had passive antibody therapy for COVID-19 in the last 90 days?..........................................
Do you have a bleeding disorder or are you taking anticoagulants (Aspirin/Warfarin/Coumadin)?....
If so, when________________________
YES NO
Feb Mar Apr
________
2021
RN
Paramedic
Student Nurse
Other________
Moderna COVID-19
Lot #
If you answered YES to any of the questions above this clinic is not able to provide the vaccine at this time.
Zip
Code: _____________
