Fillable COVID-19 Vaccine Administration Record Information collected on this

Fill Online, Printable, Fillable, Blank COVID-19 Vaccine Administration Record Information collected on this Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COVID-19 Vaccine Administration Record Information collected on this

On average this form takes 11 minutes to complete

The COVID-19 Vaccine Administration Record Information collected on this form is 2 pages long and contains:

  • 2 signatures
  • 47 check-boxes
  • 15 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
COVID-19 Vaccine Administration Record
Information collected on this form will be used to document authorization for receipt of vaccines. The information will
be shared through the Wisconsin Immunization Registry (WIR) with other health care providers directly involved with
the patient to assure completion of the vaccine schedule. Information collected on this form is voluntary and
confidential.
Client Name – First: Last: MI:
Age: Date of Birth (mm/dd/yyyy): Gender: Male Female Other
Home Address: City:
Zip: State: Telephone: Ethnicity: Hispanic Non-Hispanic
Race: Black/African American American Indian Asian White Other Race
Questions for the person receiving vaccine:
Yes
No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 vaccine?
•
If Yes, which product did you receive? Moderna Pfizer
Other:
3. Have you ever had an allergic reaction to:
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen®
or that caused you to go to the hospital.
It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory
distress, including wheezing.)
• A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in
some medications, such as laxatives and preparations for colonoscopy procedures
• Polysorbate:
• A previous dose of COVID-19 vaccine
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an
injectable medication?
o (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment
with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include
an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory
distress, including wheezing.)
•
If yes to the above, check yes if you have spoken with a physician, and that they have given you
approval to receive the COVID-19 vaccine.
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a
component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would
• include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7.
Have you been diagnosed with COVID-19 in the last 90 days?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as
treatment for COVID-19 in the last 90 days?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do
you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
12. Do you get lightheaded when receiving vaccines?
******See Consent Section on Next Page******
13. Do you have dermal fillers?
J&J
I have been given a copy and have read, or have had explained to me, information about the diseases and the vaccine to
be received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and
risks of receiving a vaccine approved under an Emergency Use Authorization from the FDA. I consent to receive the
vaccine in a public location. I have been made aware of the appropriate time I am expected to be monitored for post-
vaccination reactions based on my risk factors. I understand the benefits and risks of the vaccine requested and ask that
the vaccine be given to me, or in the case that I am a guardian, my child.
Client/guardian Signature: Date:
******VACCINATOR USE ONLY******
Vaccine IM Site Trade Name, Man. Lot Num., Exp. Date:
COVID-19 RD
LD
Signature & Title – Vaccine Administrator: Date:
R
eviewer: WIR Entry Date:
Print Name: Print DOB:
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COVID-19 Vaccine Administration Record Information collected on this

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document