Pediatric Vaccine Screening Form

Onondaga County COVID-19 Pediatric Vaccine Clinics, Ages 5 - 11
Mondays and Fridays | Nov 12, 15, 19, 22 | 9:00am- 11:30am and 1:00pm - 3:30pm
Civic Center Room 30, 421 Montgomery Street, Syracuse

You will need to download and complete this consent form and bring to your appointment.

The requested form is not available at this time.

1. Is your child sick today?*
- Yes
- No
2. Has your child been diagnosed with COVID-19 disease and are currently in isolation?*
- Yes
- No
3. Has your child been exposed to someone with COVID- 19 disease and are currently in quarantine?*
- Yes
- No
4. Has your child been diagnosed with Multisystem Inflammatory Syndrome in Children (MIS-C) in the past 90 days?*
- Yes
- No
5. Has your child been treated with antibody therapy for COVID-19 in the last 90 days (3 months)?*
- Yes
- No
6. Does your child have severe allergic reactions to any vaccine or shots in the past?*
- Yes
- No
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6. Are you currently eligible for the vaccine according to the NYS Phased Distribution Plan?*
- Yes
- No
7. Is your child of an FDA-approved age to receive the COVID-19 vaccine (5-11 pediatric Pfizer)?*
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

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