COVID Phase 1A Authorization Form

COVID Phase 1A Authorization Form
In the strategic phasing of the distribution of the vaccine, phases are implemented that sets certain classifications who are qualified to receive the vaccine. The purpose is to primarily reduce mortality and reduce the burden on healthcare providers. Now, we are at phase 1a. This phase intends to allocate the vaccine to health workers and staff, serving in healthcare or long-term care facilities. This phase may take many weeks up to months.
Phase 1a includes those workers in the frontline who have the critical risk of exposure such as doctors, athletic trainers, sign language interpreters in healthcare facilities, autopsy room staff, funeral workers, dentists including the staff, environmental services staff in healthcare facilities, medical transport personnel, admitted patients aged 65 and above, local government employees, and pharmacists.
Name of Patient/Person to Receive Vaccination
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Name of Organization
Phone Number of Organization
Please enter a valid phone number.Format: (000) 000-0000.
Email of Organization
example@example.com
Address of Organization
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Screening Questions

COVID-19 Screening

Rows	Yes	No
Do you have or have you had at any time in the last 14 days fever, chills, muscle or body aches, cough, shortness of breath, breathing difficulty, fatigue, headache, loss of taste or smell, sore throat, nasal congestion (runny nose), nausea and/or vomiting, or diarrhea?
Do you have any allergies to any vaccine or any ingredients of a vaccine?
Have you been diagnosed or tested positive for COVID-19 within the last 14 days?
Have you had any vaccination other than for COVID-19 in the last two weeks?
Have you had any COVID-19 Antibody therapy within the last 90 days (e.g. Regeneron, Bamlanivimab, COVID Convalescent Plasma, etc.)

Immunization Screening

Rows	Yes	No
Do you have allergies or reactions to any medications, foods, or latex?
Are you immunocompromised or under medication that may affect your immune system?
Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
(For women): Are you pregnant or currently breastfeeding?

Have you had a COVID-19 vaccination?
Name of COVID-19 Vaccine Manufacturer
Authorization
Name of Legal Guardian
First NameLast Name
Signature of Legal Guardian
Clear
Date Signed by Legal Guardian
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Person Administering the Vaccine
First NameLast Name
Name of Facility
Address of Facility
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Vaccine Manufacturer
Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Screening Questions