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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 immunization screening and

01

Obtain the covid-19 immunization screening form from a healthcare provider or vaccination center.

02

Fill out personal information such as full name, date of birth, address, and contact information.

03

Answer the screening questions accurately, including any recent travel history or exposure to individuals with covid-19.

04

Provide information about any pre-existing medical conditions or allergies.

05

Sign and date the form to certify the accuracy of the information provided.

Who needs covid-19 immunization screening and?

01

Individuals who are eligible to receive the covid-19 vaccine.

02

Healthcare workers who are required to undergo regular screening for potential exposure.

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What is covid-19 immunization screening?

COVID-19 immunization screening is a process used to assess an individual's vaccination status for COVID-19.

Who is required to file covid-19 immunization screening?

Employers and organizations may be required to file COVID-19 immunization screening for their employees or members.

How to fill out covid-19 immunization screening?

COVID-19 immunization screening can be filled out by providing information about the individual's vaccination status, such as dates of doses and type of vaccine received.

What is the purpose of covid-19 immunization screening?

The purpose of COVID-19 immunization screening is to track and monitor the vaccination status of individuals to prevent the spread of COVID-19.

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

Information such as vaccination dates, type of vaccine received, and any booster doses administered must be reported on COVID-19 immunization screening.

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