New York State Department of Health

Bureau of Immunization

JYNNEOS Vaccine Screening and Consent Form*

Recipient Name (please print) Preferred Name

DOB Current Gender ID Key:

W – Woman/Girl TW – Transgender Woman/Girl M – Man/Boy
Indicate ID Below: TM – Transgender Man/Boy NB – Non-Binary Person GNC – Gender Non-Conforming
Q – Not Sure/Questioning NR – Chose not to Respond
GNL - Gender not Listed (write-in)
* Gender Pronouns: write-in by client’s name
Sex Assigned at Birth Key: Marital Status Key:
Indicate Sex Below: Indicate Status Below: S – Single D – Divorced M – Married
M – Male F – Female W – Widowed V – Civil Union U –
I – Intersex NR – Chose not to Respond Unknown SEPARATED – Legally Separated
PARTNER – Life Partner
Address City State Zip Email Address

Parent/Guardian/ Surrogate (if applicable, please print) Phone Preferred Language

Ethnicity Ethnicity Key: Race Race Key:

Indicate Ethnicity Below: DECL – Declined Indicate Race Below: AIA – Native American or Alaskan ASN – Asian
HIS – Hispanic Origin BAA – African American or Black
NHL – Non-Hispanic Origin DECL – Declined
UNK – Unknown NHP – Native Hawaiian or Pacific Islander
WHT – White OTH – Other or Multiracial
Primary Insurance Name Primary Insurance ID# Subscriber Name/DOB Subscriber Relation
to Patient

Primary Insurance Address Primary Insurance Group # Primary Insurance Phone #

Secondary Insurance Name Secondary Insurance ID# Subscriber Name/DOB Subscriber Relation
to Patient

Secondary Insurance Address Secondary Insurance Group # Secondary Insurance Phone #

Clinic/Office Site Where Vaccine is Administered Primary Care Physician Address/Phone Number

Screening Questionnaire
1. Have you had a known exposure to a suspected or confirmed monkeypox case within □ Yes □ No □ Unknown
the past 14 days, or have you been diagnosed with the Monkeypox virus since
5/17/2022?
2. Are you at high risk of having had a potential recent exposure to monkeypox (within □ Yes □ No □ Unknown
the past 14 days)? This may include intimate, or skin-to-skin contact, with others in
areas where monkeypox is spreading.
3. Do you feel that you may be at risk of future exposure to monkeypox, even though □ Yes □ No □ Unknown
you are not at high risk of a recent exposure to monkeypox within the past 14 days?
4. Will you be under the age of 18 on the day of your appointment? □ Yes □ No □ Unknown
 5. Are you feeling sick today? □ Yes □ No □ Unknown

6. Have you ever had an immediate allergic reaction, such as hives, facial swelling, □ Yes □ No □ Unknown
difficulty breathing, or anaphylaxis, to any vaccine, injection, or antibiotic, or to any
component of the JYNNEOS vaccine?
7. Have you had a JYNNEOS vaccine in the last 4 weeks? □ Yes □ No □ Unknown
If so, when? Date:
8. Have you had a COVID-19 mRNA vaccine (Pfizer or Moderna) within the last 4 weeks, □ Yes □ No □ Unknown
or are you planning on receiving a COVID-19 mRNA vaccine within the next 4 weeks?
9. Are you currently pregnant, planning to become pregnant, or breastfeeding? □ Yes □ No □ Unknown

10. Are you moderately or severely immunocompromised due to one or more of the □ Yes □ No □ Unknown
medical conditions or receipt of immunosuppressive medications or treatments?
11. Do you have a history of myocarditis (inflammation of the heart muscle) or □ Yes □ No □ Unknown
pericarditis (inflammation of the lining around the heart?
12. Have you read and reviewed the Vaccine Information Statement (VIS) for the □ Yes □ No □ Unknown
JYNNEOS vaccine? (JYNNEOS dated 6/1/22)
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/smallpox-monkeypox.pdf
13. Do you understand the risks and benefits of the JYNNEOS vaccine and consent to □ Yes □ No □ Unknown
receiving the vaccine?

Consent

I have read, or had explained to me, the Vaccine Information Statement (VIS) about JYNNEOS vaccination. The VIS is also
available in Spanish: https://www.immunize.org/vis/pdf/spanish_smallpox_monkeypox.pdf. I have had a chance to ask
questions, which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. I
understand that JYNNEOS is a two (2) dose vaccine, given 28-35 days apart, and both doses are required for best vaccine
efficacy. I request that the JYNNEOS vaccination be given to me (or the person named above for whom I am authorized to
make this request).I authorize the release of any medical or other information necessary to process a Medicare or other
insurance claim or for other public health purpose. I have received a copy of the Patient Bill of Rights.

I have also been advised that I may report any adverse events that I may experience to my healthcare provider or to the
VaccineAdverse Event Reporting System at 1-800-822-7967 and www.vaers.hhs.gov.

I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the
vaccine willbe assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare
or other third parties who are financially responsible for my medical care. I authorize release of any information needed
(including but not limited to medical records, copies of claims and itemized bills) to verify payment and for other public health
purposes, including reporting to applicable vaccine registries.

Recipient/Surrogate/Guardian (Signature) Date / Time Print Name Relationship to Patient (if other than
recipient)

Telephonic Interpreter’s ID # Date / Time

OR

Signature: Interpreter Date/ Time Print: Interpreter’s Name and Relationship to Patient
 Area Below to be Completed by Vaccinator
Which vaccine is the patient receiving today?
VIS Sheet Manufacturer
Vaccine Name Subcutaneous Administration
Date & Lot #
JYNNEOS □ First Dose □ Second Dose

Administration Site □ Left Triceps Area □ Right Triceps Area

Dosage □ 0.5 ml

□ I have provided the patient (and/or parent, guardian, or surrogate, as applicable) with information about the
vaccine and consent to vaccination was obtained.

Vaccinator Signature:

* Use of this form is optional. August 4, 2022