| 1. | Is this person experiencing moderate to severe illness and/or a fever? |
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| 2. | Has this person already received the COVID Vaccine? |
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| 2a. | Which vaccine did you received? |
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| 2b. | Date Received Vaccine? |
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| 3. | Has this person had a severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine for either Pfizer-BioNTech or Moderna COVID-19 vaccines? |
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| 4. | Has this person received any type of vaccine within the past 14 days? |
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| 5. | Has this person received passive antibody therapy (monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days? |
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| 6. | Is this person Pregnant? |
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| 7. | Is this person currently breastfeeding? |
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I, the undersigned, certify that all of the above information
is correct to the best of my knowledge. I hereby authorize the recipient of this
document to share this information with public health entities at the local, state and federal
level for purposes of ensuring medication efficacy and safety. I have been
offered a copy of Privacy Practices. |