COVID-19 Vaccine Screening and Administration Form
Please correct the errors described below.
Please print neatly in capital letters. Please answer all questions as completely as possible.
Please complete ALL the information below as accurately as possible. If you are completing this form for your minor child, do not use nick-names or abbreviations, except where allowed. All information will be kept confidential.
If under 18 years of age please complete.
If you have already received your Primary Dose(s) of a COVID-19 vaccine, please tell us which vaccine(s) you received and the date(s) of vaccination.
If you have already received more than two (2) doses of a COVID-19 vaccine, please tell us which additional dose(s) you received, the vaccine(s), and the date(s) of vaccination.
Additional Dose received for High Risk Conditions
Additional Booster Dose
Health Screening Questions
Authorization to Administer COVID-19 Vaccine
I have read or had explained to me the Fact Sheet for Recipients and Caregivers for the use of the COVID-19 vaccine and understand the benefits and risks to me or my child of receiving this vaccine. I have had a chance to ask questions, which were answered to my satisfaction. I hereby release this provider, its employees and its volunteers from any liability for any results which may occur from the administration of this vaccine.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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Highlands Integrative Pediatrics
For vaccine administration guidance, including: timing, dosing, site selection, needle length and gauge, and administration procedures, please reference your standing orders or the CDC’s Interim Clinical Considerations”.
*Additional guidance from the FDA for 2nd booster dose is as follows:
A second booster dose of either the Pfizer-BioNTech COVID-19 Vaccine or Moderna COVID-19 Vaccine may be administered to individuals 50 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
A second booster dose of the Pfizer-BioNTech COVID-19 Vaccine may be administered to individuals 12 years of age and older with certain kinds of immunocompromise at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine. These are people who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.
A second booster dose of the Moderna COVID-19 Vaccine may be administered at least 4 months after the first booster dose of any authorized or approved COVID-19 vaccine to individuals 18 years of age and older with the same certain kinds of immunocompromise.
*Additional Guidance for J &J Vaccine use:
Assess persons 18 years of age and older for vaccination with Janssen COVID_19 Vaccine based on the following criteria:
mRNA COVID-19 Vaccines are preferred over Janssen COVID-19 Vaccine for primary series and booster vaccination
Inform all persons receiving a Janssen vaccine of the risks and symptoms of thrombosis with thrombocytopenia syndrome (TTS) in the 3 weeks after vaccination as was as the need to seek immediate care should symptoms develop.
Janssen COVID-19 Vaccine may be offered in some situations:
A true contraindication to mRNA vaccines (severe allergic reaction to a previous dose or a component of the vaccine.
The person would otherwise remain unvaccinated for COVID-19 due to limited access to mRNA vaccine.
The person wants to receive the Janssen COVID-19 vaccine despite the safety concerns identified.
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