COVID-19 Vaccine Screening and Immunization Documentation Form |
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COVID-19 Vaccination Program |
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The following questions will help us determine if we should give you the COVID-19 vaccination today. If you answer "yes" to any question(s), we will ask you for additional information to determine when or if you should receive COVID-19 vaccine . |
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NAME (Please Print): |
DOD ID or SSN: |
AGE: |
DOB: |
DATE: |
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CATEGORY:
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Patient: Please answer questions 1-6 |
NO |
YES |
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1 |
Are you currently sick, feel ill, or have a fever over 100°? |
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2 |
Have you received a COVID-19 vaccine before? If so, which one ? Date |
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3 |
Have you had an adverse reaction to a prior COVID-19 vaccine? |
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4 |
Are
you, or might you be,
pregnant?
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Would you like to speak with a health care team member about the COVID-19 vaccine before deciding whether or not to receive COVID-19 vaccine? |
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Do you DECLINE to receive a COVID-19 vaccine? |
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"IStatement Information Vaccine COVID-19 vaccine EUA Fact Sheet for Recipients/Caregivers or current the in information the me to explained had have or read have , as applicable.vaccine." Coronavirus the of risks and benefits the understand I satisfaction. my to answered were they and questions, ask to a chance had also have I
Signature: Date: |
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Below to be completed by Screener |
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Check box for materials provided COVID-19 Vaccine Information Statement provided
□ EUA COVid-19 Vaccine Fact Sheet for Vaccine Recipients/Caregivers |
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Screener's Signature |
Date: |
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Below to be completed by Vaccinator |
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Lot # Expiration Date: Dose: ☐ 0.5 mL ☐ Left / ☐ Right Deltoid OR PLACE STICKER HERE: |
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COMMENTS: |
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Administered by: |
Date: |
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ASIMS/MEDPROS/MRRS/AHLTA/MHS GENSIS Entry |
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Name: |
Date: |
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stg1
2020-12-17 00:22:50
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The Defense Health Agency-Immunization Healthcare Division (DHA-IHD) is available to assist patients and healthcare providers with treatment of health problems before and after vaccinations, and with medical exemptions.Please contact the DHA-Immunization Healthcare Division 24/7 Support Center at 877-438-8222.
DHA FORM XXX, OCT 2020
stg1 2020-12-16
23:56:42 -------------------------------------------- Three
of the vaccines are given as a 2-dose
series, but one is only one
dose.
stg1 2020-12-16
23:57:02 -------------------------------------------- Not
aware of any studies assess efficacy
of series with different vaccines. One of the four vaccine you have
on the first page is a 1-dose shot, the other three are 2-dose
series.
stg1 2020-12-17
00:19:50 -------------------------------------------- Guidance
will likely be similar for the Moderna
vaccine, but until FDA has
issues the EUA and ACIP has voted, we have no recommendation. We
also cannot comment on the adenovirus vaccines until those data are
made available.
stg1 2020-12-17
00:20:58 --------------------------------------------
stg1 2020-12-17
00:18:23 --------------------------------------------
Interim Clinical Considerations for Use of
Pfizer-BioNTech COVID-19
Vaccine | CDC Please see CDC language.
There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events. People with a
moderate or severe illness should not be vaccinated until their symptoms have improved. Minor illnesses with or without fever or taking antibiotics do not preclude receipt of a COVID-19 vaccine.
It is important that COVID-19 vaccine brands not be mixed. The COVID-19 vaccines are new, and studies are not
yet complete evaluating the
efficacy of vaccination if the series is not completed using the same
brand. It is also important to know the date of the first
vaccination, as different brands have different recommended intervals
between the two doses in a series.
Patients
reporting a serious reaction to a previous dose of COVID-19 vaccine
should be asked to describe
their
symptoms. Immediate – presumably allergic – reactions are usually a contraindication to further vaccination. Flu- like symptoms (malaise, myalgia, other systemic symptoms), and vaccination site reactions have been reported with COVID-19 vaccines. These mild-to-moderate reactions are not a contraindication to future vaccination.
However, moderate-to-severe non-allergic reactions including significant local reactions following vaccination should be evaluated by an experienced provider prior to revaccination.
While
no evidence
exists of
risk from
vaccinating pregnant
women with
inactivated vaccines,
and
live
vaccines
pose only a theoretical risk to the fetus, the new COVID-19 vaccines have not yet been thoroughly tested for
safety and efficacy in pregnant women. If an individual is not sure whether or not she is pregnant, she should not
receive a COVID-19 vaccine until her status is verified.
COVID-19 vaccination is voluntary. These are new vaccines for which there are, understandably, many questions. The potential vaccinee should be afforded ample opportunity to read the FDA-provided EUA Vaccine Fact Sheet and to ask questions prior to vaccination. Do not hesitate to refer an individual to an experienced healthcare provider to address questions or concerns regarding the vaccine.
An individual, after having reviewed the EUA Vaccine Fact Sheet and having had all questions addressed, may decline receipt of a COVID-19 vaccine without any impact upon their future healthcare within the MHS or their military career. For active duty service personnel, document their declination by entering the exemption code MR (medical refused) into their electronic health record and/or Services' Immunization Tracking System.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |