Updated January 15, 2021
publichealthmdc.com
Alliant Energy Center COVID Vaccine Drive-Through Clinic
Vaccine Administration Record and Screening
Information from 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 is voluntary and confidential. Please Print.
Client Name: Last: __________________________________ First:______________________________ MI:______
Age: _______ Date of Birth: month:______ day:______ year:___________ Gender: Male Female Other
Address: City: Zip:________Telephone:_________________
Ethnicity: Hispanic Non-Hispanic Race: Black/African American American Indian Asian White Other race
Questions for person receiving vaccine Yes No
1. Are you sick today? (fever, cough, shortness of breath, nausea/vomiting in the last 24 hours)
2. Are you currently in your isolation or quarantine period due to COVID-19?
3. Have you ever had an allergic reaction? If so, was it an anaphylactic reaction? Yes No
Please describe reaction and what it was to:
4. Have you received antibody therapy or convalescent plasma for COVID treatment in the past
90 days?
5. Have you received another vaccine in the past 14 days?
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
Consent obtained:__________________________________________________________ Date: _________________
Written Verbal Are you receiving Dose 1 or Dose 2?
Trade name/Manufacturer Lot Number
Signature and Title – Person Administering Vaccine: Date:
Email Address:__________________________________________
