Sussex County COVID-19 Vaccine Screening and Consent Form

Sussex County Division Of Health

201 Wheatsworth Road

Hamburg, NJ 07419

(973) 579-0570

COVID-19 VACCINE SCREENING AND CONSENT FORM

Last Name Fi rst Name Date of Birth – Age Gender (M / F)

Phone Number E-Mail Race/Ethnicity

Address City State Zi p

Primary Care Provider (PCP) Name PCP Address PCP Phone

Guardian/ Surrogate/P.O.A. (if applicable, please print)

Phone

POTENTIAL CONTRAINDICATIONS

Are you feeling sick today? (Fever, Respiratory Infection, or other

moderate/severe illness)

□ Yes

□ No

In the last 10 days, have you had a COVID-19 test or been told by a healthcare

provider

or health department to isolate or quarantine for COVID-19 infection or

exposure?

□ Yes

□ No

Have you received antibody therapy (monoclonal antibodies or convalescent

plasma) for COVID-19 in the past 90 days (3 months)?

□ Yes

□ No

Have you had any vaccines in the past 14 days (2 weeks) including flu shot?

□ Yes

□ No

Have you ever had a serious or life-threatening allergic reaction (e.g.,

anaphylaxis), such as hives or difficulty breathing, to any COVID

-19 vaccine or

any component of the vaccine, including

polysorbate or polyethylene glycol PEG

(

which is found in some medications, such as laxatives and preparations for

colonoscopy procedures)?

□ Yes

□ No

Have you tested positive for COVID-19 in the past 14 days (2 weeks)?

□ Yes

□ No

Are you under 18 years of age?

□ Yes

□ No

POTENTIAL CONSIDERATIONS

Have you ever had a serious or life-threatening allergic reaction (e.g.,

anaphylaxis), such as hives or difficulty breathing, to any vaccine?

□ Yes

□ No

Have you ever had a serious or life-threatening allergic reaction (e.g.,

anaphylaxis

), such as hives or difficulty breathing, due to any cause? (Including

medications, foods, latex, or any item.)

□ Yes

□ No

Are you currently pregnant or breastfeeding?

□ Yes

□ No

Do you have cancer, leukemia, HIV/AIDS, a history of autoimmune disease or any

other condition that weakens the immune system?

□ Yes

□ No

Do you take any medications that affect your immune system, such as cortisone,

prednisone

or other steroids, anticancer or rheumatologic drugs, or have you had any

radiation treatments?

□ Yes

□ No

Do you have a bleeding disorder or taking any blood thinner or anticoagulants?

□ Yes

□ No

Have you received a prior dose of COVID-19 Vaccine? If so, provide date.

□ Yes

□ No

Date:_________

*If you have ever had an allergic reaction to a vaccine (question 1) you will not be permitted

**If you answered yes to questions 2-5 please consult with your healthcare provider before receiving vaccine.

Staff Reviewing Form:______________________Signature:_______________________Date:__________

Sussex County Division Of Health

201 Wheatsworth Road

Hamburg, NJ 07419

(973) 579-0570

Last Name: ______________________ First Name: _____________________Date of Birth ____________

CONSENT FOR VACCINATION

EMERGENCY USE AUTHORIZATION: The FDA has ma d e the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used

when circumstances e xis t to justify the emergency use of drugs and biolog ical products during an emergency, such as t h e COVID-19 pandemic. I understand

that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus

Diseas e 2019 (COVID-19) for use in individuals 18 years of age and older; and the emergency use of this product is only authorized for the duration of the

declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the

declaration is terminated or authorization revoked sooner. However, the FDA’s decis ion to ma ke the vaccine available under an EUA is based on the existence of

a public health emergency and the totality of s cientific evidence available, showing that known and potential benefits of the vaccine outweigh th e known and

potential risks. I certify that I am: (a) the patient and at least 18 years of age; or (b) the legal guardian of the patient and confirm that the patient is at least 18

years of age; and (c) authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to the Sussex County Division of

Health or its agents to administer the COVID-19 vaccine.

CONSENT FOR SERVICES : I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am

receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my

satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I

should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. If the recipient has

previously had a severe allergic reaction in the past for any reason, I agree to wait near the clinic location for 30 minutes after receiving the vaccine in

designated area. I understand if I experience side effects that I should do the following: contact doctor, call 911, or go to hospital. I request that the vaccine be

given to me or to the person named above for whom I am authorized to make this request. I acknowledge that I have received and viewed the Vaccine

Information Statement or Emergency Use Authorization Information Sheet and Sussex County Division of Health Notice of Privacy Practices. I will/have

reviewed my answers to the questions above with the vaccinator. I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this

consent, I am agreeing that I will receive the first and second part of the vaccine series, and understand the second dose may be required to be effective. I

have been provided and have read, or had e xp lained to me , the information sheet about the COVID-19 vaccination. I have been given an opportunity to ask questions

which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was als o given a chance to ask

questions). I understand the ben efits and ris ks of the vaccine. I request that the COVID-19 vaccination be given to me (or the person named above for whom I am

authorized to make this request and provide surrogate consent).

AUTHOR I ZA TION TO REQUEST PAYMENT: I understand there will be no cost to me for this vaccine. I do hereby authorize Sussex County Division of

Health and/or its agents to release information, submit a claim, and request payment. I understand that any monies or benefits for administering the vaccine will

be assigned and transferred to the vaccinating provider. I certify that the information given by me in applying for payment under my insurance provider, Medicare

or Medicaid, other third parties who are financially responsible for my care, or the HRSA COVID-19 Program for Uninsured Patients, are correct. I authorize

release of all records to act on this request. I assign and request that payment of authorized benefits be made on my behalf to Sussex County Division of

Health or its agents with respect to the above requested items and services.

DIS CLOSURE OF RECORDS: I

understand that Sussex County Division of Health may be required to or may voluntarily disclose my health information

to the physician responsible for this protocol of specific health information of people vaccinated at Sussex County Division of Health Vaccination Sites (if

applicable), the Sussex County Division of Health and its agents, my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals,

and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also

understand that Sussex County Division of Health will use and disclose my health information as set forth in the Sussex County Division of Health Notice of

Privacy Practices (copy is available at Sussex County Division of Health, online (Sussex.nj.us) or by requesting a paper copy from the Vaccination Site).

Vaccine Clinics: If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the

clinic coordinator. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the State of New Jersey, The Sussex County

Divis ion of Health, and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all

liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed

above/herein.

________________________________________________________________________

Pati ent/ Guardian/Power of Attorney (Signature) Pri nt: Relationship to patient if not patient Date / Time

(BELOW FOR CLINIC USE ONLY)

Administ ration Facility Name: Sussex County Division of Health

Nursing Vaccine Administration Information

Vaccine

Administration

EUA Fact Sheet Date

Lot Number

Expiration Date

□ MODERNA

□ JANSSEN

□ First Dose

□ Second Dose

□ 08

/12/2021

□ 07/8/2021

Dose: 0.5mL

Route: IM

Administration Site:

□ Left Deltoid

□ Right Deltoid

□ Other ___________

Vaccinator Name:_______________________Signature:_____________________Date:_________________