Fillable COVID-19 Vaccine Consent Form (University College of Saint-Boniface)

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COVID-19 Vaccine Consent Form (University College of Saint-Boniface)

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Country of origin: CANADA
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COVID-19 Vaccine Consent Form
Sections A, B, C, D and E completed by:
□ Client □ Parent □ Legal decision maker □ Other _____________________________ (on behalf of client)
A. Client Information - please print
Surname _______________________________________________ Given Names ______________________________________
Address of residence ________________________________ City/Town _______________________ Postal Code _______________
Phone Number ___________________________ Email _______________________________________________________________
Sex
Male □ / Female □ / X □ Date of Birth (yyyy/mm/dd) _____________ / ________ / ________
Manitoba Health Number (6 digits) _______________ Personal Health Information Number (9 digits) __________________________
Name of school ________________________________________ City/Town _________________________ Grade _______________
B. Health History of Client
1. Do you have a fever or other symptoms that could be due to COVID-19?
□Yes □No
If yes, describe ____________________________________________________________________________________________
2. Do you have any known or suspected allergies (examples: food, medications, environmental)?
□Yes □No
If yes, describe ____________________________________________________________________________________________
3. Do you have a known or suspected allergy to polyethylene glycol (PEG), polysorbate 80 or tromethamine?
□Yes □No
4. Have you ever had a serious reaction or condition following any vaccine?
□Yes □No
If yes, describe ____________________________________________________________________________________________
5 Do you have any medical conditions that require regular visits to a doctor?
□Yes □No
If yes, please discuss with immunizer ___________________________________________________________________________
6. Have you received a vaccine in the last 14 days?
□Yes □No
7. Are you taking any medication that affects blood clotting?
□Yes □No
If yes, please list ___________________________________________________________________________________________
8. Are you pregnant, planning to become pregnant or breastfeeding?
□Yes □No
9. Is your immune system suppressed due to disease (e.g., leukemia) or treatment (e.g,. high-dose steroids)?
□
□
Yes □No
10. Do you have an autoimmune condition (e.g., Rheumatoid Arthritis, Multiple Sclerosis)? Yes
□No
11. Do you have a history of venous sinus thrombosis in the brain or a history of heparin-induced thrombocytopenia (HIT)?
□Yes □No
12. Have you received any doses of a COVID-19 vaccine?
□0 Doses □Dose 1 □Dose 2
13.Have you received a monoclonal antibody treatment (e.g., Sotrovimab, Casirivimab, Imdevimab)
for a COVID-19 infection in the last 90 days?
□Yes □No
C. Racial, Ethnic or Indigenous Identity
Public health has been collecting information about the racial, ethnic, Indigenous identity of individuals who are diagnosed with
COVID-19 since May 2020. The following questions will help assess vaccine coverage and determine the need for increased vaccine
accessibility in different communities. We recognize that this list of racial or ethnic identiers may not exactly match how you would
describe yourself. Keeping that in mind, which of the following best describes the racial or ethnic community that you belong to?
□African □Black □Chinese □
□ □
Filipino □Latin American □North American Indigenous – that is, First Nations, Metis or Inuit
South Asian Southeast Asian
□White □Other _________________________________________ □Prefer not to answer
If you identied as North American Indigenous, do you identify as:
□First Nations □Metis □Inuit □Not Applicable
D. Informed consent – Consult immunizer if no signature can be obtained
I have read and understood the fact sheet(s) regarding the risks and benets of the vaccine that I am consenting be administered to the
above named person as per section A. My consent applies to all doses of the vaccine necessary to complete the series up to one year.
I have had the opportunity to ask questions about the vaccine(s) which were answered to my satisfaction.
Complete ONLY ONE of the following two options:
1. Consent by legal decision maker 2. Consent by client
I consent to the above named person receiving the COVID-19 vaccine. I consent to receiving the COVID-19 vaccine.
Name __________________________________________________ Date (yyyy/mm/dd) _______________________________
Relationship _____________________________________________ Signature ______________________________________
Phone number ___________________________________________
Date (yyyy/mm/dd) ________________________________________
Signature _______________________________________________
E. Consent for use and disclosure of contact information
I understand and authorize the Department of Health and Seniors Care’s use and disclosure of the contact information provided by me
on this form to a third party organization for the sole purpose of
Date __________________________________________
contacting me to schedule my appointment for the second dose
of the vaccine. Signature ______________________________________
MHSU-2823 (December 2021)
Notice: Information about the immunizations you or your dependent(s) receive may be recorded in the provincial immunization registry. This registry
allows your health care providers to nd out what immunizations you or your dependent(s) have had or need to have. Information collected in the
provincial immunization registry may be used to produce immunization records, or notify you or your doctor if a particular immunization has been
missed. Manitoba Health and Seniors Care may use the information to monitor how well different vaccines work in preventing disease. The Personal
Health Information Act protects your information. You can have your personal health information hidden from view from health care providers. For more
information, please contact your local public health ofce to speak with a public health nurse www.manitoba.ca/health/publichealth/ofces.html.
THE FOLLOWING SECTION TO BE COMPLETED BY THE IMMUNIZATION PROVIDER
Clinic Location _____________________________________________________________________________________________
□ Check this box if verbal consent has been obtained from client because they are unable to sign section D
Reason for Immunization – please check the
rst reason that applies (Check ONLY the rst box that
applies)
1.
□ Personal care home resident
2.
□ Health care worker (includes all settings)
3.
□ Community with disproportionate disease impact
4. □ Other congregate living (includes residents,
non-health care staff, visitors, volunteers)
5.
□ Routine (age)
The following ve interventions must be performed and documented with
a check mark by the immunizer:
1. □ Fact sheet(s) provided
2. □ Section B completed and reviewed
3. □ Expected benets and material risks of vaccine provided
4. □ Information provided about reporting vaccine side effects
(reportable side effects pursuant to section 57(2) of the
Public Health Act)
5. □ Concerns and questions addressed
Clients who answer yes to questions 9, 10 and/or are receiving dose 3 (as per question 12) of section B: health care provider
or immunizer must review the expected benets and material risks of vaccination as per the Clinical Practice Guidelines.
Immunizer or Health Care Provider Name (please print): _____________________________________________________________
Immunizer or Health Care Provider Signature: ________________________________________ Date __________________________
Vaccine
Date
Y/M/D
Lot # Manufacturer Route Dose Site Immunizer's Signature
Data
Entry
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COVID-19 Vaccine Consent Form (University College of Saint-Boniface)

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Completed 3 February 2022

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