COVID-19-Vaccine-Consent-Form

COVID-19 Vaccine Consent Form

NAME (Last)	(First)	(M.I.)
DATE OF BIRTH: month____________________ day_____ year __________

Section 1: Information about person to receive vaccine (please print)

Section 2: Screening for Vaccine Eligibility

The following questions will help us to know if you can get the updated COVID-19 vaccine. A “yes” answer to any of the questions does not necessarily mean the vaccine cannot be given, but additional questions may be asked.

Please mark Yes or No for each question.	Yes	No	Don’t Know
1. Do you have a health condition or undergoing treatment that makes you moderately or severely immunocompromised?	⁭	⁭	⁭
2. Have you ever had any severe allergic reaction that has required treatment with epinephrine or caused you to go to the hospital? Please list:__________________________________________________	⁭	⁭	⁭
3. Have you ever had an allergic reaction to a component of a COVID-19 vaccine or a previous dose of COVID-19 vaccine?	⁭	⁭	⁭
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?	⁭	⁭	⁭
4. Do you have a history of any of the following: (Mark any that apply) • Myocarditis or pericarditis • Multisystem Inflammatory Syndrome • An immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia (HIT) • Thrombosis with thrombocytopenia syndrome (TTS) • Guillain-Barré Syndrome (GBS) • COVID-19 disease within the past 3 months • Vaccinated with mpox (orthopoxvirus) vaccine in the last 4 weeks?	⁭	⁭	⁭

Section 3: Education (Check each box after reading)

I acknowledge that I am aware of the following:

COVID-19 is a contagious virus that can be spread from person to person through respiratory droplets. COVID-19 can cause mild to severe illness and death has occurred in some people.
The updated COVID-19 vaccine is recommended for me to help prevent the spread of the disease to residents, friends, family and staff. This vaccine may protect me from getting COVID-19, or minimize the symptoms if I get infected.
I understand that the updated COVID-19 vaccine will help protect me by creating an antibody (immune system) response without having to experience sickness.
I understand that there can be side effects associated with the vaccine such as pain, swelling, redness to the injection site. I may potentially experience tiredness, headache, muscle pain, chills, fever or nausea.
I understand that the vaccine may be given as a single or multiple dose(s) of the current updated formulation based on my vaccination history, immune status, and manufacturer’s recommendations.
I have been given a copy of the most current Emergency Use Authorization Fact Sheet/VIS for the __________________________ (insert brand) COVID-19 vaccine and have been educated on the risks, benefits, and potential side effects of the vaccine.

Section 4: Consent

CONSENT FOR VACCINATION:

I have been educated on and understand the risks, benefits and potential side effects of the updated COVID-19 vaccine and hereby give consent for ________________________________ (resident or staff name) to receive the ___________________________ (brand) COVID-19 vaccine.

__________________________________________________ ______________________

(Resident, Resident representative, or staff member signature) (Date)

Section 5: Declination

DECLINATION OF VACCINE:

I have been educated on and understand the risks, benefits, and potential side effects of the updated COVID-19 vaccine, but at this time I decline the updated COVID-19 vaccination for the following reason(s): ____________________________________________________________________________________.
I understand that I can change my mind at any time and accept the updated COVID-19 vaccination at a later time and will receive current education at that time.

__________________________________________________ _____________________

(Resident or Resident representative signature) (Date)

Section 6: Vaccination Status

ALREADY RECEIVED VACCINE: (provide copy of card)

I have already received a prior vaccination(s):

Date Received	Vaccine Brand	Monovalent	Bivalent

____________________________________________________ ______________________

(Resident, Resident Representative, or staff member signature) (Date)