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Vaccination Consent Form for people receiving COVID-19 vaccine

 PART 1: PERSONAL DETAILS

Birthday
Day
Month
Year

PART 2: MEDICAL DETAILS

1. Has this person ever had a serious allergic reaction (anaphylaxis) that needed medical treatment?
Yes
No

 i. after having a previous dose of the Moderna (Spikevax®) or any Pfizer/BioNTech (Comirnaty®) COVID-19 Vaccines, OR ii. to any of the vaccine ingredients, including polyethylene glycol known as PEG, OR iii. to Trometamol (an ingredient in a contrast dye used in MRI radiological studies)? If yes, they cannot have this vaccine. If no, GO TO NEXT QUESTION.

2. Have they ever had a serious allergic reaction (anaphylaxis):
Yes
No

 i. after taking multiple different medications, with no reason known for the reaction. This may mean they are allergic to polyethylene glycol (PEG), OR ii. after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR iii. for unexplained reasons? This may mean they are allergic to polyethylene glycol (PEG). If yes, they cannot get this vaccine today, they should get specialist advice. Talk to the vaccination team. If no, GO TO NEXT QUESTION.

3. Have they ever had Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body’s tissues)
Yes
No

If yes, they can still get the vaccine, BUT, they should be observed for 30 minutes after they are vaccinated. If no or yes, GO TO NEXT QUESTION.

4a. Since they had myocarditis or pericarditis after a previous dose of COVID-19 vaccine a specialist doctor (Cardiologist) must approve that they can get this vaccine. Has their COVID-19 vaccination been approved by a specialist doctor (Cardiologist)?
Yes
No

 If yes, GO TO NEXT QUESTION. If no, they cannot get this vaccine today. They should talk to their specialist doctor (Cardiologist) to check if they are suitable for this vaccine.

5. Have they had an mpox vaccine (Imvanex or JYNNEOS) in the last 4 weeks?
Yes
No

 If yes, they need to wait 4 weeks before getting a COVID-19 vaccine. If no, GO TO NEXT QUESTION.

6. Have they had a previous COVID-19 infection?
Yes
No

If yes and they have been vaccinated against COVID-19 previously then they should wait at least 3 months since their last infection or vaccine before getting vaccinated. If yes and receiving a first ever dose of a COVID-19 vaccine, they should delay getting a vaccine until they have recovered from COVID-19 and it has been at least 4 weeks since they tested positive or developed symptoms. If no, GO TO NEXT QUESTION.

7. Do they have a bleeding disorder or are they on anticoagulation therapy?
Yes
No

If yes, they can still get a vaccine if they have a bleeding disorder or take anticoagulation medicines. But tell their vaccinator about their condition. If no, GO TO NEXT SECTION.

 Question 8 for children and young people aged 5 to 17 years

8. Has this child or young person had multisystem inflammatory syndrome also called MIS-C (a rare syndrome usually treated in hospital) after a COVID-19 infection?
Yes
No

If yes, please answer question 8a and 8b. If no GO TO NEXT SECTION.

8a. Has this child or young person clinically recovered from MIS-C?
Yes
No

 If yes, GO TO QUESTION 8b. If no, they will have to wait until they have clinically recovered from MIS-C.

8b. Has it been over 3 months since this child or young person was diagnosed with MIS-C?
Yes
No

If yes, GO TO NEXT SECTION. If no, they will have to wait at least 3 months after the diagnosis of MIS-C before they can be vaccinated.

Complete this section if they are getting a second or third dose of a COVID-19 vaccine after their first dose because they have a weak immune system (immunocompromise)

9.Are they receiving a second dose of a COVID-19 vaccine 4 weeks after their first dose because they have a weak immune system?
Yes
No

 If yes, GO TO QUESTION 9a. If no, GO TO QUESTION 10.

9a.Has it been at least 4 weeks since their 1st dose of the vaccine?
Yes
No

 If yes, GO TO QUESTION 9b. If no, they should wait at least 4 weeks since their last dose.

9b.Have they been diagnosed with COVID-19 infection since their first dose of COVID-19 vaccine?
Yes
No

If yes, they should wait at least 4 weeks from when they tested positive or developed symptoms before getting their second vaccine. If no, GO TO NEXT QUESTION

10.Are they receiving a third dose of a COVID-19 vaccine after their second dose on the advice of a specialist doctor?
Yes
No

If yes, go to Question 10a. If no, GO TO NEXT SECTION.

10a. If yes, has it been at least 4 weeks since their last COVID-19 vaccine dose?
Yes
No

If yes, go to question 10b. If no, they should wait at least 4 weeks since the last COVID-19 vaccine.

10b. If they are receiving a third dose of a COVID-19 vaccine after their second dose because they have a weak immune system, have they had COVID-19 infection since their second COVID-19 vaccine dose?
Yes
No

 If yes, the vaccinator will advise if they need a vaccine based on current NIAC advice. If no, GO TO NEXT SECTION.

 Please complete the following questions if the person is pregnant

11a. Have they already had a COVID-19 vaccine in this pregnancy?
Yes
No

 If yes, they should be informed that usually in pregnancy, only one dose is offered. However, if they are pregnant and immunocompromised, a second dose of the vaccine may be considered if it has been more that 6 months since their last vaccine or infection. They should speak to their healthcare provider. If no, GO TO QUESTION 11b.

11b. Have they had COVID-19 infection or a COVID-19 vaccine in the last 6 months?
Yes
No

If yes, they should wait at least 6 months from their last COVID-19 infection or COVID-19 vaccine dose to get vaccinated.

 Please note that the interval between last infection or last vaccination is different in pregnancy. If eligible, a COVID-19 vaccine can be given at any time in pregnancy but ideally should be given between 20 and 34 weeks of pregnancy.

 PART 3: VACCINATION CONSENT

One of these options 1-3 is appropriate when establishing consent (please tick as appropriate)
1. The individual has consented to vaccination with COVID-19 vaccine and has been provided with written information, OR
2. The individual does not agree with COVID-19 vaccination and should not be vaccinated, OR
3. The individual cannot consent and they are being vaccinated with COVID-19 vaccine according to their benefit and will and preference, AND

 The above is recorded in their healthcare record and includes information about any consultation that has taken place to help determine their will and preference.

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