Patient Name
Sheet #
Informed Consent
I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if this vaccine requires
two doses, two doses of this vaccine will need to be administered (given) in order for it to be effective. I have been given an opportunity to ask questions
which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a
Screening Questionnaire
1. Have you ever had a serious or life-threatening allergic reaction, such
as your throat closing or difficulty breathing?
2. Are you feeling sick today?
3. Have you had any vaccine within the past 14 days?
4. In the last 10 days, have you been told by a healthcare provider or
health department to isolate or quarantine at home due to COVID-19
infection or exposure?
5. Have you been treated with monoclonal antibody therapy for
treatment of COVID-19 in the past 90 days? (need to wait 90 days from
last treatment)
6. Are you UNDER 18 years old?
Page 1 CVVax2.8
Patient Temp
Clinician Initials
If you answered 'Yes' or 'Unknown' to any question 1-6, you cannot get a vaccine today (you may be able to get one at your doctor's office)
Patient/Guardian/Surrogate Signature:_____________________________________________
Patient/Guardian/Surrogate Printed Name:_________________________________________
Witness Printed Name:_________________________________________________________________
Witness Signature:______________________________________________________________________
Relationship to Patient_________________________________________________________________
chance to ask questions). I understand the benefits and risks of the vaccination as described. I understand all COVID vaccine treatments are reported to CIR for
vaccine tracking purposes. I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request
and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine
will be assigned and transferred to the vaccinating provider, including benefits/monies from my health insurance plan, Medicare, Medicaid or other third parties
who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims
and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
Emergency Use Authorization
The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products
during an emergency, such as the COVID-19 pandemic. This vaccine has not completed the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine
available under an EUA is based on the existence of a public health emergency and the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the
known and potential risks.
Page 1 of 2
Patient DOB
COVID-19 Vaccine Screening and Consent Form
7. Are you pregnant and/or breastfeeding?
8. Do you have cancer, leukemia, HIV/AIDS, a history of autoimmune
disease or any other condition that weakens the immune system?
9. Do you take any medications that affect your immune system, such as
cortisone, prednisone or other steroids, anticancer drugs, or have you
had any radiation treatments?
10. Is this your first dose of COVID vaccine?
If second dose: Date of first dose_______ Manufacturer of first dose:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Vaccine Information - Clinician Use Only
Injection Site:
Vaccine Dose #1 - Pfizer 0.3mL IM
Vaccine Dose #2 - Pfizer 0.3mL IM
If dose 2: Date of dose 1_________
I, ________________________, have reviewed side effects with patient (and parent,
guardian or surrogate, as applicable). I confirm that the patient (and their surrogate, if
applicable) was given an opportunity to ask questions about the vaccination, and all the
questions asked by them (and/or their surrogate) have been answered correctly and to the
best of my ability.
Page 2 CVVax 2.8
Marital Status
Educational Material:
EUA Fact Sheet provided - Moderna - version 12/2020
EUA Fact Sheet provided - Pfizer - version 12/2020
Astra- Zeneca
Clinician Signature:________________________________ Clinician Initials:_________ Date:__________
Company Name
Company Location
*Note- dose #1 and dose #2 should be from the same manufacturer
Page 2 of 2
Vaccine Dose #1 - Moderna 0.5mL IM
Vaccine Dose #2 - Moderna 0.5mL IM
If dose 2: Date of dose 1_________
Administration Information:
Lot 026L20A expires 6/28/2021