Fillable COVID-19 Vaccination Form Please complete each field below (Oklahoma State University)

Fill Online, Printable, Fillable, Blank COVID-19 Vaccination Form Please complete each field below (Oklahoma State University) Form

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COVID-19 Vaccination Form Please complete each field below (Oklahoma State University)

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Clinic:_________________________________________ Today’s Date: ____________________
OSDH/CHS/CERS
ODH 1401 /12-29-2020
COVID-19 Vaccination Form Please complete each field below with the information that applies to the client receiving services today.
CLIENT INFORMATION
Name (Last, First, MI)
Suffix (eg., Jr, III)
Date of Birth
Age†
Street Address
City
State
Zip
Phone Number
Cell
( ) Home
Sex
Female
Male
Other Unknown
Race
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander White Other
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino Unknown
If the client is under 18 years of age, please complete guardian information.
Guardian relationship to client:
Father
Mother
Legal Guardian
Other Guardian Name (Last, First) _______________________________________________________
CONSENT FOR SERVICE
I, the undersigned, give my consent for the services that I am requesting from the Oklahoma State Department of Health (OSDH) and its entities/contractors. I understand that:
-- the risks and benefits for these services will be explained to me and that I will have the opportunity to ask questions.
-- the information regarding myself and the services I receive will be entered into OSDH management information systems and may be used for program evalu
ation,
management, and billing purposes.
-- I may refuse service at any time.
I acknowledge that I have received a copy of the Oklahoma State Department of Health Privacy Statement as required by the Health Information Portability and Accountability
Act (HIPAA). I can also find a copy on the agency website. I also acknowledge that I received the manufacturer-specific Fact Sheet for Recipients and Caregivers prior to
receiving the vaccine.
Client/Guardian Sign
ature: _____________________________________________________________________________________ Date: _____________________________
, ,
, ,,,,
†Client must be aged 16 years or older to receive the Pfizer vaccine and aged 18 years or older to receive the Moderna vaccine
OSDH/CHS/CERS ODH 1401/12-29-2020
****FOR OSDH USE ONLY****
Client Name (Last, First, MI) __________________________________________________ Client DOB (MM/DD/YYYY)__________________________________
OFFICE USE ONLY – DO NOT WRITE BELOW
Vaccine Manufacturer:
Lot #:
Exp. Date:
Site:
LT DELTOID IM
RT DELTOID IM
LT VAST LAT IM
RT VAST LAT IM
EUA*/VIS given? Y N
Reaction? Y N
Dose Number:
1
st
2
nd
Vaccination Complete? Complete Refused Not administered Partially administered No recorded completion status
Provider Signature:
*EAU = Emergency Use Agreement
Progress Note:___________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
, ,
Client completed the manufacturer's screening questions: Y N
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COVID-19 Vaccination Form Please complete each field below (Oklahoma State University)

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Completed 29 November 2021

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