American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
E X A M P L E 1 2 3
Please print neatly in capital letters as shown in
the example below
Street Name
Street No. or PO Box
Last Name
Zip Code
Date Administered
COVID/VFC PIN
Apt. Number
Prescribing Provider Name
County
Phone
Provider Type: Public Private
M M D D Y Y Y Y
M M D D Y Y Y Y
Colorado COVID-19
Vaccine Administration and Screening Form
Please answer all questions as completely as possible
First Name
Personal Information. Provide information as completely as you can. All information will be kept confidential.
City
MI
State
Gender Identity
M F Non-
Binary
Date of Birth
/
/
-
-
E-mail
Race/Ethnicity (Check all that apply)
Asian
Black, African American
Hispanic/Latino
White
Other
Decline to Provide
Health Screening Questions
Yes*
No
1A-Highest risk: Direct contact w COVID patients, LTC staff/residents
Please identify Phase Category you are in (please choose only one)
2-Higher risk and other essential workers: Age 60-69; Individuals age 16-59 with
obesity, diabetes, chronic lung disease, significant heart disease, chronic kidney
disease, cancer, or are immune compromised; 2) Other essential workers and
continuity of local government; 3) Adults who received the placebo in Clinical Trials.
Authorization to Administer COVID-19 Vaccine
I have read or had explained to me, and I understand the risks and benefits of receiving the COVID-19 vaccine. I have had a chance
to ask questions, which were answered to my satisfaction. I hereby release this provider, its employees and its volunteers from any
liability for any results which may occur from the administration of this vaccine.
Patient, Parent/Guardian Signature: _________________________________________
Date: ____________
STOP - DO NOT WRITE BELOW THIS LINE
Manufacturer
PFR (Pfizer) AstraZeneca/
Moderna
Oxford Biomedica
SP/GSK J&J
0.3 ml
0.5 ml
Dosage
Site:
LD LT
RD RT
Lot No.
Administered by:
Name _______________________________________
Title __________
/
/
Rev. 02/08/2021
Clinic Name
1. Are you sick today?
2. Do you have a serious allergy to food, a vaccine component, or latex?
3. Have you ever had a serious reaction to a previous dose of vaccine or any medication?
4. Have you had severe allergic reaction to any component of either of the mRNA COVID-19 vaccines licensed in the US?
5. Are you pregnant, or is there a chance you may become pregnant in the next 14 days?
6. Have you received any vaccinations in the last 14 days?
7. Have you been ill with or recovered from a confirmed COVID infection within the past 3 months?
8. Have you had convalescent plasma or monoclonal antibodies as part of COVID-19 treatment in the past 3 months?
9. Do you have any of the following illnesses or conditions?
Chronic lung disease (including asthma), heart disease, diabetes, brain, spinal cord or muscle illness that causes
swallowing or lung problems, problems with the immune system caused by medications and/or HIV, kidney disease, liver disease, blood disorders
1B-Moderate Risk: Moderate risk HCW’s; first responders, age 70 +; Frontline essential
workers and continuity of state government: 1) Health care workers with less direct contact
(home health, hospice, pharmacy, dental, etc.), EMS; 2) Firefighters, police, COVID-19 response personnel,
corrections, funeral services; 3) Frontline essential workers- Education (teachers, daycare); Food &
Agriculture, Manufacturing; USPS; Public transit and specialized transportation services; Grocery; Public
Health; frontline essential human services workers and direct care providers for Coloradans experiencing
Homeless; 4) Essential officials from Executive, Legislative and Judiciary Branches of state gov.; 5) Essential
frontline journalists
3-General Public: Anyone ages 16-59
Un-
specified
Decline
to
Provide
First Dose Second Dose
Time __________
click to sign
signature
click to edit
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