Please fill out the information in the form below. Once completed, print the form and bring it with you for your vaccination appointment.

Section 1: Vaccine Recipient Information

Section 2: Screening for Vaccine Eligibility

Section 3: Health Status Review

Provider note is required prior to receipt of vaccine.

Section 4: Consent

I have read or have had explained to me the information provided in the Energency Use Authorization (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me.

Internal Use Only

Immunization Date Lot # & Expiration Date Dosage, Route & Site (circle) Vaccinator Signature Entered in IRIS Date and Initials

0.5 mL IM

L deltoid or R deltoid

COVID-19 Vaccine EUA FACT SHEET for Recipients and Adult Vaccination Card provided.