COVID-19 Vaccine Checklist

• Completed on

  Date

• Completed by

• Location
  Address

• Are you 18 years of age and older?

  Yes

  No

• If you are below 18 years of age, please consult with your vaccination provider regarding the minimum years of age you must be to receive this vaccine.

Allergies to Ingredients

• If you answer yes to any of the questions in this section, it is highly likely that you should not be given this vaccine. Consult with your vaccination provider for more information.

• Are you allergic to or have had a severe allergic reaction to nucleoside-modified mRNA encoding the viral spike (S) glycoprotein of SARS-CoV-2 ?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to viral vector; recombinant, replication-incompetent adenovirus type 26 expressing the SARS-CoV-2 spike protein?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to 2 [(polyethylene glycol)-2000]-N,N-ditetradecylacetamide?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to PEG2000-DMG: 1,2-dimyristoyl-rac-glycerol, methoxypolyethylene glycol?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to polysorbate-80?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to 1,2-Distearoyl-sn-glycero-3- phosphocholine?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to 2-hydroxypropyl-β-cyclodextrin (HBCD)?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to (4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate)?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to SM-102: heptadecan-9-yl 8-((2-hydroxyethyl)(6-oxo-6-(undecyloxy) hexyl) amino) octanoate?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to citric acid monohydrate?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to trisodium citrate dihydrate?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to tromethamine?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to tromethamine hydrochloride?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to monobasic potassium phosphate?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to potassium chloride?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to dibasic sodium phosphate dihydrate?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to sodium chloride?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to sodium hydroxide?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to sodium acetate?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to acetic acid?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to hydrochloric acid?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to ethanol?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to sucrose?

  Yes

  No

• Are you allergic to or have had a severe allergic reaction to cholesterol?

  Yes

  No

• Have you had a severe allergic reaction after a previous dose of this vaccine?

  Yes

  No

• If you answered yes to any of the questions in this section (Allergies to Ingredients), it is highly likely that you should not be given this vaccine. Consult with your vaccination provider for more information.

To Notify Vaccination Provider

• Do you have any allergies?

  Yes

  No

• If you answered yes to the previous question, kindly specify the type of allergies you have:

• Do you have a fever?

  Yes

  No

• If you answered yes to the previous question, kindly select the date when the fever began:

  Date

• When the fever began, what was your initial temperature?

• Please indicate if the temperature is in Celsius or Fahrenheit:

  Celsius

  Fahrenheit

• Before answering this checklist, when did you last take your temperature? Please select the date and nearest time.

  Date

• The last time you took your temperature, what was it?

• Please indicate if the temperature is in Celsius or Fahrenheit:

  Celsius

  Fahrenheit

• Do you have a bleeding disorder or are on a blood thinner?

  Yes

  No

• If you answered yes to the previous question, kindly specify what bleeding disorder you have and/or what blood thinner you are on:

• Are you immunocompromised or are on a medicine that affects your immune system?

  Yes

  No

• If you answered yes to the previous question, kindly specify what causes you to be immunocompromised and/or what medicine is affecting your immune system:

• Are you pregnant or planning to become pregnant?

  Yes

  No

• Are you breastfeeding?

  Yes

  No

• Have you received another COVID-19 vaccine?

  Yes

  No

• If yes, what vaccine was it?