Please complete the screening information below, then press the �Next� button at the bottom of the page for a printable voucher.

* The questions in this form are based on criteria for the Moderna vaccine only. This form should not be used to determine eligibility for COVID-19 vaccines from any other manufacturer.

Personal Information

	First Name:	Last Name:
	Address:
	Address2/Other:
	City:	State/Terr.: --Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming  Zip/Postal Code:
	Telephone:	( ) -
	Email:
	Race:	--Select One-- American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Unknown/Unreported
	Ethnicity:	--Select One-- Hispanic Non-Hispanic Unknown/Unreported
	Date of Birth:	/ /
	Sex:	Male Female

Medical Information*
	1.	Is this person experiencing moderate to severe illness and/or a fever?	Yes No
	2.	Has this person already received the COVID Vaccine?	Yes No
	2a.	Which vaccine did you receive?	Pfizer Moderna
	2b.	Date recieved the vaccine? / /
	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?	Yes No
		- For a list of Moderna vaccine components, please refer to the Emergency Use Authorization (EUA) .
		- For a list of Pfizer vaccine components, please refer to the Emergency Use Authorization (EUA) .
	4.	Has this person received any type of vaccine within the past 14 days?	Yes No
	5.	Has this person received passive antibody therapy (monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days?	Yes No
	6.	Is this person Pregnant?	Yes No
	7.	Is this person currently breastfeeding?	Yes No
By checking the "I Agree" box, I acknowledge that I have been offered a copy of the Emergency Use Authorization Fact Sheet and I consent for the vaccine to be given to me or the person named above for whom I am authorized to sign. If there are any questions, please contact your local Health Department.
I Agree
	After completing the screening information, press the �Next� button for a printable voucher.