NY COVID-19 Immunization Screening and Consent Form 2021-2026 free printable template

New York State Department of Health Bureau of ImmunizationCOVID19 Immunization Screening and Consent Form* Recipient Name (please print)Preferred Tameka: W Woman/Girl TW Transgender Woman/Girl M Man/Boy

How to fill out NY COVID-19 Immunization Screening and Consent

How to fill out NY COVID-19 Immunization Screening and Consent Form

1. Obtain the NY COVID-19 Immunization Screening and Consent Form from a healthcare provider or online resource.
2. Fill in your personal information, including your name, date of birth, and contact details.
3. Indicate your insurance information if applicable.
4. Answer the screening questions regarding your medical history, allergies, and previous COVID-19 vaccinations.
5. Review the consent section and sign the form to give permission for the vaccination.
6. Date the form and submit it to the healthcare provider administering the vaccine.

Who needs NY COVID-19 Immunization Screening and Consent Form?

1. Individuals who are receiving the COVID-19 vaccination in New York.
2. Parents or guardians filling out the form for minors receiving the vaccine.
3. Anyone who is completing the COVID-19 vaccination process at a designated facility.

People Also Ask about

What should be documented when administering a vaccine?

The following information must be documented on the patient's paper or electronic medical record or on a permanent office log: The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered. The name, office address, and title of the healthcare provider administering the vaccine.

How do I refuse a flu shot?

Covered Individuals who choose to decline influenza vaccination must complete a Vaccine Declination Letter and submit it to the location vaccine authority on or before December 1, 2022.

What are valid reasons to decline the flu shot?

Reasons for Refusing the Flu Vaccine “I do not need the vaccination” (17.3%) “I might experience side effects or get sick from the vaccine” (12.2%) “I don't think the vaccination is effective in preventing flu” (11.8%).

What information is included in a vis?

What's a VIS? A VIS or Vaccine Information Statement is a document, produced by CDC, that informs vaccine recipients – or their parents or legal representatives – about the benefits and risks of a vaccine they are receiving.

What are acceptable reasons to not get the flu shot?

People with excuses why they don't “want” or “need” flu vaccine should reconsider. Excuse #1 - “I don't get the flu.” Excuse #2 “The influenza vaccine doesn't work.” Excuse #3 “The flu shot makes me sick.” Excuse #4 “I already had the flu earlier this year.” Excuse #5 “I have an egg allergy.”

What is the meaning of immunization screening?

The Immunisation Screening Form indicates whether documentation is required or not, and if required, the acceptable evidence of immunity for each vaccine preventable disease which may be: Vaccination records (e.g. childhood, school or travel vaccination records)

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What is NY COVID-19 Immunization Screening and Consent Form?

The NY COVID-19 Immunization Screening and Consent Form is a document that individuals must complete prior to receiving a COVID-19 vaccination, ensuring that they understand the vaccine, its risks, and their consent to be vaccinated.

Who is required to file NY COVID-19 Immunization Screening and Consent Form?

Individuals who are receiving the COVID-19 vaccine in New York are required to complete the NY COVID-19 Immunization Screening and Consent Form.

How to fill out NY COVID-19 Immunization Screening and Consent Form?

To fill out the NY COVID-19 Immunization Screening and Consent Form, individuals should provide personal information, answer screening questions related to health history, and sign the form to give consent for vaccination.

What is the purpose of NY COVID-19 Immunization Screening and Consent Form?

The purpose of the NY COVID-19 Immunization Screening and Consent Form is to screen individuals for any contraindications to the vaccine and to obtain informed consent before administering the COVID-19 vaccine.

What information must be reported on NY COVID-19 Immunization Screening and Consent Form?

The information that must be reported on the NY COVID-19 Immunization Screening and Consent Form includes personal details like name and date of birth, health history relevant to vaccination, any allergies, and consent for vaccination.