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COVID-19 Vaccine Administration Permission

  1. SCREENING, CONSENT, AND ADMINISTRATION RECORD

    PRICE COUNTY HEALTH AND HUMAN SERVICES | 104 S. EYDER AVE. | PHILLIPS, WI 54555

  2. Gender
  3. My child attends:*
  4. Has your child ever received a dose of COVID-19 vaccine?*
  5. If yes, which vaccine?*
  6. Has the person to be vaccinated ever had an allergic reaction to?*

    - A component of a COVID-19 vaccine, including either of the following: Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures OR Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.

    - A previous dose of COVID-19 vaccine.

    This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.

  7. Has the person to be vaccinated ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?*

    This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.

  8. Check all that apply to your child:
  9. Informed Consent

    Information collected on this form will be used to document authorization for receipt of vaccines. The information will be shared with the Wisconsin Immunization Registry (WIR). Information collected on this form is voluntary and confidential. I have been given a copy and have read, or have had explained to me, information about the diseases and the vaccine to be received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of receiving a vaccine approved under an Emergency Use Authorization from the FDA. I have been made aware of the appropriate time I am expected to be monitored for post-vaccination reactions based on my risk factors. I ask that the vaccine be given to my child.

  10. Electronic Signature Acknowledgement*

    I wish to submit this administration form by electronic means. By signing this permission form, I certify, that my answers are correct and complete to the best of my knowledge. I understand the questions and statements on this permission form. I understand that an electronic signature has the same legal effects and be enforced the same way as a written signature.

  11. Leave This Blank:

  12. This field is not part of the form submission.