The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Covid-19 Vaccine Screening & Consent

Today's Date

* must provide value

M-D-Y

First Name

* must provide value

Last Name

* must provide value

Middle Initial

Gender

* must provide value

Male

Female

Other

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[Optional] Last 4 of Social Security Number. This will help us find your insurance information

Date of Birth (MM/DD/YYYY)

* must provide value

M-D-Y

Age (years)

* must provide value

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Street Address

* must provide value

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Phone Number

* must provide value

Are you a USC Employee or USC Student?

* must provide value

Yes

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Please enter your 10-digit Employee/University ID Number:

* must provide value

Email Address

The following information is requested to report to the California Immunization Registry (CAIR): Mother's First Name

Race (choose one)

* must provide value

American Indian / Alaskan

Asian

Native Hawaiian or Other Pacific Islander

Black / African-American

White

Other Race

Unknown Race

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Ethnicity (choose one)

* must provide value

Hispanic or Latino

Not Hispanic or Latino

Unknown Ethnicity

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What type of health insurance do you have?

* must provide value

Medi-Cal/Medicaid

Medicare

Private Insurance (ex. Anthem, Blue Cross)

Kaiser Permanente

Other insurance

None

I don't know

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[Optional] Please upload a photo or copy of the FRONT of your health insurance card.

Upload file

[Optional] Please upload a photo or copy of the BACK of your health insurance card.

Upload file

Have you ever received a dose of the COVID-19 Vaccine?

* must provide value

Yes

I Don't Know

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If Yes, Which Covid-19 vaccine did you receive?

* must provide value

Moderna

Pfizer

Janssen

I don't know

Other

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How many doses of the COVID-19 vaccine have you already received?

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What is the date of your most recent COVID-19 Vaccine?

M-D-Y

YES

I DON'T KNOW

Are you feeling sick today?

* must provide value

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Have you ever had an allergic reaction to Polyethylene Glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?

* must provide value

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Have you ever had an allergic reaction to polysorbate (which is found in some vaccines, film coated tablets, and intravenous steroids)?

* must provide value

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Have you ever had an allergic reaction to citric acid or ethanol?

* must provide value

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Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine?

* must provide value

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Have you ever had an allergic reaction to any vaccine or injectable therapy?

* must provide value

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Have you ever had a severe allergic reaction (e.g., anaphylaxis) to anything? This would include food, pet, environmental, or oral medication allergies.

* must provide value

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Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

* must provide value

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Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19 within the last 90 days?

* must provide value

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Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

* must provide value

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Do you have a bleeding disorder or are you taking a blood thinner?

* must provide value

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Are you pregnant or breastfeeding?

* must provide value

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Do you have dermal fillers?

* must provide value

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Do you have a history of herparin-induced thrombocytopenia (HIT)/ ¿Tienes antecedentes de trombocitopenia inducida por heparin (HIT)?

* must provide value

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Have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?

* must provide value

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Do you have a history of myocarditis or pericarditis?

* must provide value

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Do you have a history of Guillain-Barré Syndrome (GBS)

* must provide value

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Have you ever had an allergic reaction to any of the following (check all that apply to you):

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.

A previous dose of COVID-19 vaccine

Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures

Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids

Citric acid or ethanol

Another vaccine (other than COVID-19 vaccine) or an injectable medication

Check all that apply to you:

Feeling sick today

Have a history of myocarditis or pericarditis

Have been treated with monoclonal antibodies or convalescent serum to prevent or treat COVID-19

Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection

Have a bleeding disorder or take a blood thinner

Have a history of heparin-induced thrombocytopenia (HIT)

Am currently pregnant or breastfeeding

Have received dermal fillers

Have a history of Guillain-Barre Syndrome (GBS)

Do you have a health condition or are you undergoing treatment that makes you moderately or severely immunocompromised?

(This would include treatment for cancer or HIV, receipt of organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-call therapy, hematopoietic cell transplant [HCT], DiGeorge syndrome or Wiskott-Aldrich syndrome).

YES

I DON'T KNOW

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Have you received a hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 Vaccine?

YES

I DON'T KNOW

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CLICK "ADD SIGNATURE" THEN USE YOUR MOUSE OR FINGER TO SIGN

I understand and acknowledge that vaccinations are being provided by licensed personnel through USC Pharmacy.

I hereby release, discharge and hold harmless University of Southern California and USC Pharmacies, and its officers, directors, employees, members, subsidiaries, agents, successors, and assigns from any and all liability that may arise, directly or indirectly, now or in the future, by reason of any injury, damage, loss, or expense incurred in connection with my receiving a vaccination today.

I certify that the information provided above has been completed to the best of my knowledge.

I understand that all COVID-19 vaccinations provided by USC Pharmacies are by appointment only, and that completion of this form does not constitute an appointment.

I have reviewed (or will have the opportunity to review) the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers or Vaccine Information Sheet (VIS), if applicable, and had (or will have) a chance to ask questions that were answered to my satisfaction. I fully understand the possible risks and side effects of vaccinations.

I consent to the vaccination being provided for myself or the person named above for whom I am authorized to make this request.

Unless I decline, I understand that this information will be reported to the California Immunization Registry or CAIR.

I authorize the USC Pharmacies to release information and request payment to my health plan. I certify that the information given by me in applying for payment is correct. I request that the payment of authorized benefits be made on my behalf. To sign, please click "Add signature" then use your mouse or finger to create a signature.

As of 08/13/2021- COVID-19 VACCINE SELF ATTESTATION OF ELIGIBILITY FOR ADDITIONAL DOSE (MODERNA; PFIZER)

This attestation below applies to those who have a moderately to severely weakened immune system, who
have already received 2 doses of Pfizer or Moderna COVID-19 vaccine.

If you meet the criteria outlined by the CDC, it is recommended that you get a 3rd dose of an mRNA
(Pfizer or Moderna) vaccine at least 28 days after your 2nd dose of vaccine. When possible, you
should receive the same vaccine. For example, if you got a series of Pfizer vaccine, try to get a Pfizer
vaccine for your 3rd dose. Talk to your doctor about the need to get a 3rd dose of COVID-19 vaccine
and the best timing of a 3rd dose.

I attest that I am immunocompromised and am eligible for a third dose of vaccine based
on the criteria below.

Receiving active cancer treatment for tumors or cancers of the blood;
Received an organ transplant and am taking medicine to suppress my immune system;
Received a stem cell transplant within the last 2 years or am taking medicine to suppress
the immune system;
Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, WiskottAldrich syndrome);
Advanced or untreated HIV infection;
Active treatment with high-dose corticosteroids or other drugs that suppress my immune
response

As of 09/24/2021 - COVID-19 VACCINE SELF ATTESTATION OF ELIGIBILITY FOR BOOSTER DOSE (PFIZER)

If you meet the criteria outlined by the CDC, it may be recommended that you get a booster dose of an mRNA (Pfizer) vaccine at least 6 months after your 2nd dose of vaccine.

I attest that I meet CDC recommended criteria for a booster dose of the Pfizer Vaccine.

CDC recommends:

people 65 years and older and residents in long-term care settings should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series,
people aged 50–64 years with underlying medical conditions should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series,
people aged 18–49 years with underlying medical conditions may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks, and
people aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks.

As of 10/22/2021 - COVID-19 VACCINE SELF ATTESTATION OF ELIGIBILITY FOR BOOSTER DOSE (JANSSEN, MODERNA, PFIZER)

If you meet the criteria outlined by the CDC, it may be recommended that you get a booster dose of a COVID-19 vaccine.

I attest that I meet CDC recommended criteria for a booster dose of the COVID-19 VACCINE.

CDC Recommends:

All people who received the J&J vaccine for their primary series should get a single vaccine Booster dose at least 2 months after their initial J&J dose (could be J&J, Pfizer, or Moderna [half dose])
The following people should get a booster dose at least 6 months after the 2nd dose of their primary Pfizer or Moderna vaccine series
- People aged 65 years and older
- People aged 18 years and older who live in long-term care settings o people aged 50–64 years who have underlying medical conditions or who experience social and economic risks that place them at increased risk for COVID-19
The following people may get a booster dose at least 6 months after the 2nd dose of their Pfizer or Moderna primary vaccine series, based on their individual benefits and risks:
- People aged 18–49 years with underlying medical conditions
- People aged 18–64 years at increased risk for COVID-19 exposure and transmission because of their occupational or institutional setting; this includes all essential workers

* must provide value

If signed by another other than the patient, please mark the box below to describe your relationship to the patient.

Parent

Guardian

Healthcare Agent

Other Authorized Individual

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