Zanesville-M
uskingum County Health Department 205
North 7
th
Street, Zanesville, OH 43701
Phone 740-454-9741 www.zmchd.org
Screening Questionnaire for Covid-19 Vaccination
Person to be vaccinated: ________________________________Date of Birth:______________ Age Today:__________
Address:
Street
City
Zip Code
Phone Number: ______________ Email:____________________
Is this your first or second dose in the last month? ☐ First dose ☐ Second
PATIENT QUESTIONS – ANSWER THE DAY OF VACCINATION
☐ No ☐ Yes Have you had any type of vaccine in the last two weeks?
☐ No ☐ Yes Have you ever had a severe allergic reaction to a vaccine or any injection in the past?
☐ No ☐ Yes Have you come in contact with someone who has tested positive for COVID-19 in the last two weeks?
☐ No ☐ Yes Have you tested positive or being monitored for COVID-19 in the last two weeks?
☐ No ☐ Yes Have you received antibody therapy (monoclonal or convalescent plasma) for COVID-19 in the last 3 months?
☐ No ☐ Yes Do you have any serious health conditions (often called co-morbidities)?
☐ No ☐ Yes Do you have a weakened immune system (i.e., from HIV or cancer) or are you on immunosuppressive drugs?
☐ No ☐ Yes Do you have a bleeding disorder or are you taking a blood thinner?
☐ No ☐ Yes Are you pregnant or breastfeeding?
☐ No ☐ Yes Do you currently or have you in the past 14 days, had a fever, chills, cough, shortness of breath, difficulty breathing,
Fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?
What group ar
e you in? (select only one)
To be fille
d out by the immunizer: Patient Temperature __________________________ Date____________________
If patie
nt answers yes to any of these questions or patient’s bodily temperature is 100° F or greater, please inform them that they should not receive the vaccine at this time, instruct
them to contact their primary care provider for next steps and that the facility coordinator will be notified.
I have read information given to me about Covid-19 and the Covid-19 vaccine. I believe I understand the benefits and risks of this vaccine and ask that the vaccine be
given to the person named above. The privacy policy has been offered to me, and I agree to the HIPAA policies therein. I am aware that this information will be
entered into IMPACT SIIS, the Statewide Immunization Information Registry. I also authorize ZMCHD to release my information and request payment from my
insurance company.
Date: Signature of Self or Guardian:
RACE:
☐ Alaskan Native ☐ Native Hawaiian
☐ American Indian ☐ Pacific Islander
☐ Asian ☐ White
☐ Black ☐ Other
☐
Unknown
ETHNICITY:
☐ Hispanic/Latino
☐ Not Hispanic/Latino
☐ Unknown
SEX
☐ Female
☐ Male
☐ Other
☐ Unknown
Screener_____________
Da
te/Time____________
What group are you in? (select only one)
☐ Assisted Living Facility Resident
☐ Assisted Living Facility Staff
☐ Skilled Nursing Facility Resident
☐ Skilled Nursing Facility Staff
☐ State of Ohio DODD Resident
☐ State of Ohio DODD Staff
☐ State of Ohio Veterans Home Resident
☐ State of Ohio Veterans Home Staff
☐ State of Ohio MHAS Resident
☐ State of Ohio MHAS Staff
☐ State of Ohio DRC LTC Resident
☐ State of Ohio DRC LTC Staff
☐ Congregate Care Facility Resident
☐ Congregate Care Facility Staff
☐ Hospital worker Clinical Staff
☐ Hospital worker Administrative Staff
☐ Hospital worker Ancillary Staff
☐ Non-Hospital healthcare worker Clinical Staff
☐ Non-Hospital healthcare worker Administrative Staff
☐ Non-Hospital healthcare worker Ancillary Staff
☐ Emergency Medical Services EMTs/ Paramedics
☐ Individuals over 80 years of age
☐ Individuals age 75 to 79 years of age
☐ Individuals age 70 to 74 years of age
☐ Individuals age 65 to 69 years of age
☐ Individuals with congenital disorders or early onset
conditions with IDD
☐ Individuals working in K-12 schools
☐ Individuals with Congenital Disorders or Early in Life
Conditions that Carried into Adulthood without DD
☐ Diabetes Type 1
☐ Pregnant
☐ Bone Marrow Transplant Recipient
☐ ALS
☐ Childcare Services Worker
☐ Funeral Services Worker
☐ Law Enforcement, Corrections, Firefighter
☐ Diabetes Type 2
☐ End Stage Renal Disease
☐ Individuals age 60 to 64 years of age
☐ Individuals age 50 to 59 years of age
Ver. 03/10/21
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