Fillable COVID-19 VACCINATION SCREENING & ENCOUNTER FORM (County of Campbell)

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COVID-19 VACCINATION SCREENING & ENCOUNTER FORM (County of Campbell)

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COVID-19 VACCINATION SCREENING & ENCOUNTER FORM
DATE: VDH Client ID#
Last Name
M F
Home Phone
Provider Printed Name Signature Date
CHS-2b_COVID (12/21/20)
Patient, Parent/Legal Guardian, Person Acting in Loco Parentis -Printed Name Signature Date
SCREENING QUESTIONNAIRE ON BACK
I consent to receive vaccination information or reminders by Text message Email
I hereby authorize the administration of the COVID-19 vaccine to myself or to the person named below for whom I am the legal representative.
I have read or have had explained to me the COVID-19 Emergency Use Authorization fact sheet and understand the risks and benets. I have had
the opportunity to ask questions about this immunization. I believe the benets outweigh the risks, and I accept full responsibility for any reactions
that may result from my receipt of the immunization or the receipt of the immunization by the person named below for whom I am the legal
representative. I agree that the immunization record may be shared as stated in the Notice of Privacy Practices, which includes sharing with
health care providers and to support the application for payment by Medicare, Medicaid, or other third party payer. I request the third party
payer to pay any authorized benets to VDH on my behalf. The Notice of Deemed Consent for blood borne diseases has been explained to me
and I understand it.
Cell Phone Email
Gender Race
American Indian/Alaskan Native Black or African American Hispanic/LatinoAsian
Hawaiian Native or Other Pacic Islander White Not Stated
Yes No
State Zip
Address
(Not a PO Box)
Street
City
First Name Middle Name Birth Date
NOTICE OF DEEMED CONSENT FOR HIV, HEPATITIS B OR C TESTING
VDH is required by § 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:
1. If any VDH health care professional, worker or employee should be directly exposed to your blood or body uids in a way that may
transmit disease, your blood will be tested for infection with human immunodeciency virus (HIV, as well as for Hepatitis B and C. A
physician or other health care provider will tell you the result of the tests. Under Va. Code § 32.1-45.1(A), you are deemed to have consented
to the release of the test results to the person exposed.
2. If you should be directly exposed to blood or body uids of a VDH health care professional, worker or employee in a way that may
transmit disease, that person’s blood will be tested for infection with human immunodeciency virus (HIV), as well as for Hepatitis B
and C. A physician or other health care provider will tell you and that person the result of the tests.
VACCINES ADMINISTERED ICD-10 Z23
Item Code Lot Number/NDC Route Administration Site Provider #
COVID-19-MOD (0.5 mL) Moderna IM RA LA
Admin code (circle one) Moderna 1st dose 0001A 2nd dose 0002A
COVID-19-PFR (0.3 mL) Pzer IM RA LA
Admin code (circle one) Pzer 1st dose 0011A 2nd dose 0012A
RECEIPT OF THE NOTICE OF PRIVACY PRACTICES
I acknowledge that I have read the Notice of Privacy Practices from the Virginia Department of Health.
COVID-19 PRE-VACCINATION SCREENING QUESTIONNAIRE
The following questions will help us determine if there is any reason we should not give you, or the person for whom you are the
legal representative, the COVID-19 vaccination today. If you answer “yes” to any question, it does not necessarily mean you should not
be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to
explain it.
Please answer the following questions for the person being vaccinated:
1.
Are you feeling sick today?
□Yes □No □Don’t know
2.
Are you pregnant or do you plan to become pregnant?
□Yes □No □Don’t know
3.
Are you breastfeeding?
□Yes □No
4.
Have you ever received a dose of COVID-19 vaccine?
□Yes □No □Don’t know
If yes, which vaccine product?
□Pzer □Another product______________________________
5.
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which
you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
□Yes □No □Don’t know
•
Was the severe allergic reaction after receiving a COVID-19 vaccine?
□Yes □No □Don’t know
•
Was the severe allergic reaction after receiving another vaccine or another injectable medication?
□Yes □No □Don’t know
6.
Do you have a bleeding disorder or are you taking a blood thinner?
□Yes □No □Don’t know
7.
Have you received passive antibody therapy as treatment for COVID-19?
□Yes □No
8.
Are you immunocompromised or do you take a medicine that affects your immune system?
□Yes □No
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COVID-19 VACCINATION SCREENING & ENCOUNTER FORM (County of Campbell)

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Completed 3 April 2021

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