Please take the time to download and read this updated Janssen (Johnson and Johnson) COVID-19 Vaccine EUA Fact Sheet (Jul/08/2021)
Last Name
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First Name (Legal Name)
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Date of Birth (MM-DD-YYYY)
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M-D-Y
You must be 18 years of age or older to receive this vaccine
* must provide value
I entered the wrong age I do not meet the age requirments
Gender
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Female
Male
Other
Transgender
Unknown
Female
Male
Other
Transgender
Unknown
Local Address Line 1
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State
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AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code
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Email Address (OU email preferred)
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Phone Number (cell phone number preferred)
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Is this address your permanent address?
* must provide value
Yes
No, address is temporary
Yes
No, address is temporary
Have you tested positive for COVID-19 within the last 14 days, or are you waiting on results for a COVID-19 test you took because you had an exposure or are having symptoms?
* must provide value
Yes
No
Are you experiencing symptoms that could be consistent with COVID-19, such as fever, cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, recent loss of taste or smell, and/or extreme fatigue?
* must provide value
Yes
No
Have you had close contact (been within 6 feet, for approximately 15 minutes or more), either at work, at home or in the community, with an individual diagnosed with COVID-19 in the last 14 days or with someone who has been tested for COVID-19 and whose results are pending in the last 14 days? If so, you will need to be cleared by a public health official before receiving your vaccine.
* must provide value
Yes
No
Are you a female aged 18 through 49 years of age?
* must provide value
Yes
No
Please confirm that you have read, understand, and agree to the following statement:
Blood clots involving blood vessels in the brain, abdomen, and legs along with low levels of platelets (blood cells that help your body stop bleeding), have occurred in some people who have received the Janssen COVID-19 Vaccine. In people who developed these blood clots and low levels of platelets, symptoms began approximately one to two-weeks following vaccination. Most people who developed these blood clots and low levels of platelets were females ages 18 through 49 years. The chance of having this occur is remote. You should seek medical attention right away if you have any of the following symptoms after receiving Janssen COVID-19 Vaccine: • Shortness of breath, • Chest pain, • Leg swelling, • Persistent abdominal pain, • Severe or persistent headaches or blurred vision, • Easy bruising or tiny blood spots under the skin beyond the site of the injection.
* must provide value
Yes
No
Follow up on "Yes" response to
Have you had any other vaccine in the last 14 days?
Please provide further information.
Above you indicated receiving passive antibodies (e.g. monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days.
It is recommended that you delay vaccine by 90 days after passive antibody therapy. Unless you keyed in the wrong response above, please end your survey now.
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End survey now
Continue survey and re-key the passive antibodies response above
End survey now
Continue survey and re-key the passive antibodies response above
Follow-up to "Yes' Response to:
I have health conditions, medical history, or concerns about receiving the COVID-19 Vaccine.
Please provide further information.
Follow-up to "Yes' Response to:
Do you have a fever of 100.3 F or greater today?
Please provide further information.
Follow-up to "Yes' Response to:
Do you have severe allergies or reactions to any medications, vaccines, or latex (including anaphylaxis to any substance)?
Please provide further information.
Follow-up to "Yes' Response to:
Have you had a severe allergic reaction after a previous dose of the COVID-19 Vaccine?
Please provide further information.
Follow-up to "Yes' Response to:
Do you have a bleeding disorder or take anticoagulation medication (e.g. Coumadin/warfarin, Heparin, Lovenox/enoxaparin, Fragmin, blood thinner, etc.)?
Please provide further information.
Follow-up to "Yes' Response to:
Do you have any condition (e.g. cancer, HIV/AIDS, rheumatoid arthritis) or take any medications that weakens or compromises your immune system (radiation, steroids). *Will not prevent you from getting the vaccine.
Please provide further information.
Follow-up to "Yes' Response to:
For women, are you or will you be nursing, pregnant, or plan to become pregnant during the course of the multi-phase COVID-19 Vaccine protocol? *Will not prevent you from getting the vaccine.
Please provide further information.
Which dose of the Janssen COVID-19 vaccine will you receive with the appointment?
* must provide value
Dose 1
Dose 2
A COVID-19 vaccine booster (second) dose is recommended for persons 2 months after receipt of the initial Janssen (Johnson & Johnson) dose.
Do you meet the time interval criteria?
Yes
No
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Ethnicity
* must provide value
Hispanic
Not Hispanic or Latino
Unknown
Prefer not to answer
Hispanic
Not Hispanic or Latino
Unknown
Prefer not to answer
Parent or legal guardian (for all patients under 18 years of age).Please note that the Johnson & Johnson Vaccine is currently authorized for 18 and above.
First Name Last Name Address Line 1 Address Line 2 City State Zip Relationship Telephone Number:
AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
SERVICES REQUEST AND AUTHORIZATION:
I understand the benefits and risks of the COVID‐19 Vaccination, and I voluntarily assume all risks and take full responsibility for any reactions that may result. I understand I should remain in the vaccine administration area for 15‐30 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should, as appropriate: contact a doctor, call the vaccine provider or call 911 if it is an emergency. I hereby waive any and all claims for damages arising out of or related to this vaccination that I (or anyone claiming on my behalf) may have against OU Health Services and/or the Board of Regents of the University of Oklahoma, including, but not limited to any and all representatives of each, such as (by way of example and not limitation) employees, students, regents, directors, officers, and other healthcare providers of whatever designation. I request that the COVID‐19 Vaccine be given to me or the person named herein, for whom I am authorized to make this request and give consent. I understand and consent to the vaccination being administered by any qualified nurse, student of its Colleges of Pharmacy or Nursing (under the supervision of the respective College’s healthcare professional), or other qualified healthcare provider.
AUTHORIZATION TO REQUEST MEDICARE, MEDICAID, or HRSA REIMBURSEMENT:
In the event I do not have private insurance, I authorize the University or OU Health Services, as applicable, to release information and request reimbursement for administration of this vaccine. I certify that the information given by me for applying for reimbursement by Medicare, Medicaid, or HRSA COVID-19 Program for Uninsured Patients is correct. I authorize the release of all records necessary for reimbursement. I request that payment of authorized benefits be made on my behalf.
DISCLOSURE OF RECORDS:
I understand that a record of my immunization will be maintained and the provider, University or OU Health Services, may be required to or may voluntarily disclose my health information to a physician, health care professional, hospital, clinic , laboratory, pharmacy, medical facility, my insurance plan, and/or state or federal registries, for purposes of treatment, payment, or other health care operations. I also understand that that my health information may be used and disclosed as set forth in the Notice of Privacy Practices maintained by each entity and copies are available as follows:
University: https://apps.ouhsc.edu/hipaa/hpp.asp or contact OU Office of compliance - (405) 271-2511; Anonymous OU Compliance Hotline - (405) 271-2223 / (866) 836-3150.
Signature of patient to receive COVID-19 Vaccine (or parent, guardian, or authorized representative):
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date:
Parent, guardian, or authorized representative:
First Name Last Name Relationship: Phone:
Today's Date (MM-DD-YYYY)
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Today M-D-Y
Please indicate the status of the person who will be receiving the vaccine
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OU Student
OU Employee
Dependent of OU Employee
Dependent of OU Student
Other
OU Retiree
OU Student
OU Employee
Dependent of OU Employee
Dependent of OU Student
Other
OU Retiree
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Health Insurance Card
Please upload or take a photo of your insurance card with your phone/mobile device and then upload it to this box.
The insurance card is being collected to request insurance reimbursement for vaccine administration. If you do not have health insurance, please upload a picture of your ID.
You will not incur any charges for this vaccination.
Please enter your OU ID number listed on the front of your ID card,
(Please enter 0 if you do not have an OU ID.)
* must provide value
Submit
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