CLEARLY TYPE or PRINT information below about the person receiving the vaccine OR CIRCLE correct responses.
Last Name ____________________________ First Name ______________________ M_________________
Birth date ______ /______ /______
Sex: F M Other
Ethnicity: Hispanic or Latino Not Hispanic or Latino Prefer not to answer
Race:
American Indian/Alas
ka Native Asian Black/African American Prefer not to answer
Native Hawaiian/Other Pacific Islander White Other Race/Multiracial
Home Address: ______________________________ City: ____________________ State: IL
County: __________________ Phone # (______) ________________
Please answer all the questions below.
1.
2.
3.
YES NO
4.
YES NO
Are you under 18 years of age? …………………………………………………………………………………………………….....
Are you experiencing moderate or severe acute illness with or without fever including any COVID
symptoms?...........................................................................................................................................
5.
YES NO
6.
Have you ever had a serious reaction to a vaccine/injectable medication (e.g.,anaphylaxis)?..............
YES NO
7.
8.
Are you allergic to any of the ingredients in the COVID vaccine?.........................................................
YES NO
Have you tested positive for COVID?...................................................................................................
YES NO
YES NO
Are you currently in quarantine or isolation?.........................................................................................
NOTE: Please continue to protect yourself and others from COVID-19 with good hand washing, wearing a
mask, maintaining social distance of at least 6 feet from others, and staying home when you are ill.
Signature_________________________________
_
Relation:__________________ Date:_____/_____/______
(if m
inor, parent or legal guardian must sign)
Administration Date
(Circle Month/Enter Day)
Vaccine
Administrator
Signature Title (circle one)
Route
IM
Dose
Administered
R deltoid
L deltoid
0.5 mL
I-CARE: Initials_______ Date ______________
MODERNA
MODERNA SARS-CoV-2 Vaccine (COVID-19)
2020-2021 CONSENT FORM AND ADMINISTRATION RECORD
(Circle)
Have you had passive antibody therapy for COVID-19 in the last 90 days?..........................................
Do you have a bleeding disorder or are you taking anticoagulants (Aspirin/Warfarin/Coumadin)?....
If so, when________________________
YES NO
RN
Paramedic
Student Nurse
Other________
If you answered YES to any of the questions above this clinic is not able to provide the vaccine at this time.
Zip
Code: _____________
Clinic Site:
Kane County Health Department
FOR ADMINISTRATIVE USE ONLY
Moderna COVID-19 Lot #
Vaccine Manufacturer
Organization
Oct Nov Dec
________2021
CONSENT
I
have been given and read the Emergency Use Authorization (EUA) for the Moderna Vaccine and have had my questions
answered about COVID-19 vaccine. I understand the benefits and the risks of the COVID-19 vaccine and ask that the vaccine be given
to me. Moderna primary series requires 2 doses, 28 days or more apart, to be fully effective. I agree to obtain the second dose. I
confirm that I fall within the Illinois Department of Public Health (IDPH) current eligible vaccination group. I consent to the
administration of the vaccine by representatives of Kane County Health Department (KCHD). I fully release and discharge KCHD, Kane
County Government, its affiliates and their officers, directors, employees and persons acting on their behalf or at their direction from
any liability or claim related to the administration of, or my receipt of, the vaccine.
I attest I am eligible for the vaccine I am requesting per IDPH guidelines.
cr. 01/07/20
rv #18_10/21/21
0.25 mL
