• MORGAN COUNTY HEALTH DEPARTMENT CONTRAINDICATION CHECKLIST FOR COVID-19 VACCINATIONS 2020/2021

  • Thank you for expressing interest in receiving the COVID-19 vaccine. This form may be used by eligible members of the current vaccine distribution group as defined by the Centers for Disease Control (CDC). 

  • DATE OF BIRTH*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender (please select one)*
  • Format: (000) 000-0000.
  • IS YOUR ETHNIC HERITAGE HISPANIC OR LATIN-AMERICAN?*
  • Format: (000) 000-0000.
  • Do you have health insurance?*
  • Is this insurance policy held in your name?
  • Insured Person's Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please bring your insurance card(s) to your immunization appointment.

  • Please answer the following questions:

  • Is the person to receive vaccine sick today?*
  • Has the person to be vaccinated ever had a severe allergic reaction (anaphylactic)?*
  • Did the severe allergic reaction (anaphylactic) reaction occur after receiving a vaccine or injectable medication?*
  • Did the severe allergic reaction (anaphylactic) occur after receiving a COVID-19 vaccine?*
  • Has the person to be vaccinated previously received one or more doses of any COVID-19 vaccine?*
  • If YES, which product (choose one):
  • Has the person to be vaccinated received passive antibody therapy such as monoclonal antibodies (Regeneron) or convalescent plasma in the last 90 days?*
  • Has the person to be vaccinated received any other vaccines/immunization in the last 14 days?*
  • Is the person to be vaccinated breastfeeding or pregnant or plans to become pregnant in the next 30 days?
  • Should be Empty:
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