Transcription of Screening Questionnaire
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Screening Questionnaire
For IRMC Use Only: Dose: 1 2 3 PA SIIS _____ FIN: _____ COVID-19 immunization Screening and Consent Form Recipient Name (Please Print) _____ First Middle Last Date of Birth _____ Social Security: _____ Legal Gender: Male Female Race: _____ Ethnicity: Non-Hispanic Hispanic Declined Address: _____ County: _____ City: _____ State:_____ Zip Code: _____ Primary Phone Number: _____ Employer: _____ Insurance Company/Plan_____ Member ID: _____ If a Medicare Advantage Plan, please list your Medicare number from the red/white/blue card.
COVID-19 Immunization Screening and Consent Form Recipient Name (Please Print) ... information needed for public health purposes including reporting to applicable vaccine registries. The parent or guardian of children age 17 and younger must sign this consent form prior to the child receiving the vaccine.
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