COVID-19 VACCINE ADMINISTRATION RECORD
COVID-19 Vaccine Administration Record Page 1 of 2
Version 12-16-2020
(Please PRINT clearly)
Today’s Date:
Legal Name:
Last Name First Name Middle Name
Date of Birth: Other Names Used Since Birth:
MM/DD/YYYY
(Maiden Name, etc.):
☐ Male ☐ Female
Address:
Street Address
City State Zip Code
Phone Number:
(Area Code) Phone Number
☐ White
☐ Black/African American
☐ Asian
☐ Native Hawaiian/Pacific Islander
☐ Native Alaskan/American Indian
☐ Multi-Racial (Select all that apply)
☐ Non-Hispanic/Latino
☐ Hispanic/Latino
I have read or have had explained to me, the information contained in the Emergency Use Authorization
Fact Sheet regarding the vaccine(s) to be administered today. I have had a chance to ask questions which were answered to my
satisfaction. I believe I understand the benefits and risks of the specific vaccine(s). I ask that the vaccine(s) be given to me, or to the
person for whom I am authorized to make this request. I also authorize the Macomb County Health Department to release my
immunization record information, or the immunization record information of the person for whom I am authorized to make this request
to other health care provider(s) as needed and to other public health authorities (e.g. for entry into an immunization registry for
Covid-19 Vaccine reporting requirements).
NOTICE OF PRIVACY PRACTICES:
I have received notification of the Macomb County Health Department’s Notice of Health
Information Practices. I understand that my acknowledgement of the Notice is evidenced by my signature on this document. The
Department is required to abide by the terms of this privacy notice. The Department may change the terms of its notice at any time.
The new notice will be effective for all protected health information that it maintains at that time. Upon my request, the Department will
provide me with the revised notice of privacy practices.
ereby acknowledge that I have read and fully
understand the applicable statements on this form.
SIGNATURE of Client/Legal Guardian
Date
PRINT NAME of Client/Legal Guardian
1. Are you currently ill or running a fever?
☐ Yes ☐
2. Have you received any vaccine within the past 14 days?
☐ Yes ☐
3. Have you ever had a severe allergic reaction to any of the following items?
☐ Yes ☐
Vaccine
Medication or Therapy
Food Item
4. Do you have a low platelet count or a bleeding disorder?
☐ Yes ☐
5. Are you currently pregnant or breastfeeding?
☐ Yes ☐
6. Have you previously been treated for COVID-19 with monoclonal antibodies
or convalescent plasma?
☐ Yes ☐
