COVID-19 Vaccine Administration Record
(for recipients that are not in facilities serviced by Mediprocity)

For Pharmacist/Immunizer Use ONLY

Vaccine Recipient

COVID-19 Screening Interview Questions	Yes	No	Don’t Know
1. Are you feeling sick?*
2. Have you ever received a dose of COVID-19 Vaccine? If yes, which vaccine product did you receive?* Pfizer     Moderna     Janssen     Other
3. Have you ever had an allergic reaction to Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?*
4. Have you ever had an allergic reaction to Polysorbate, which is found in some vaccines, filmcoated tablets, and intravenous steroids?*
5. Have you ever had an allergic reaction to a previous dose of COIVD-19 vaccine?*
6. Have you ever had an allergic reaction to another vaccine (other than the COVID-19 vaccine) or an injectable medication?*
7. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than acomponent of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.*

8. Have you received any vaccine in the last 14 days?*
9. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?*
10. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*
11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*
12. Do you have a bleeding disorder or are you taking a blood thinner?*
13. Are you pregnant or breastfeeding?*
14. Do you have dermal fillers?*

Responses to these questions are not (on their own) contraindications or precautions to vaccination. However, healthcare professionals should be prepared to discuss information and options with patients based on their responses to the following questions. If the immunizer is unable to determine if the patient can safely receive the vaccination, do not administer the vaccination, and immediately notify the Director of Pharmacy.

Vaccine Administration Information (fill in all fields)	First Vaccination	Second Vaccination	Bivalent Booster Dose
Administration Date
Manufacturer	Pfizer Moderna Janssen	Pfizer Moderna	Pfizer Moderna
Vaccine Administered
EUA Date
NDC
Lot Number
Expiration Date
Route	IM	IM	IM
Site:	Left Deltoid Right Deltoid	Left Deltoid Right Deltoid	Left Deltoid Right Deltoid

Pharmacist/Immunizer Information

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