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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

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How to fill out covid-19 vaccine screening and

01

Obtain the covid-19 vaccine screening form from the designated healthcare facility.

02

Fill out your personal information accurately including name, date of birth, contact information, and any relevant medical history.

03

Answer all questions on the form regarding your health status, any symptoms you may be experiencing, and any recent exposure to covid-19.

04

Sign and date the form to certify that all information provided is true and accurate.

05

Submit the completed form to the healthcare provider administering the covid-19 vaccine.

Who needs covid-19 vaccine screening and?

01

Individuals who are planning to receive the covid-19 vaccine at a healthcare facility.

02

People who have been advised by healthcare professionals to undergo covid-19 vaccine screening.

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What is covid-19 vaccine screening?

Covid-19 vaccine screening is a process to assess individuals for eligibility and safety before administering the Covid-19 vaccine.

Who is required to file covid-19 vaccine screening?

Healthcare providers and facilities administering the Covid-19 vaccine are required to conduct and file vaccine screenings.

How to fill out covid-19 vaccine screening?

Covid-19 vaccine screenings can be filled out by collecting relevant medical information and assessing eligibility criteria set by health authorities.

What is the purpose of covid-19 vaccine screening?

The purpose of covid-19 vaccine screening is to ensure that individuals receive the vaccine safely and without adverse effects.

What information must be reported on covid-19 vaccine screening?

Information such as medical history, allergies, current medications, and any past adverse reactions to vaccines must be reported on Covid-19 vaccine screening.

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