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Self-declaration form for coronavirus vaccination

Published Updated

Here is a self-declaration form that can be used for coronavirus vaccination. This is a voluntary tool for structuring the collection of necessary information in connection with coronavirus vaccination.

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Self-declaration form before vaccination

This can be filled in by the person to be vaccinated, brought on the vaccination day where the vaccinator can use it as documentation until electronic registration is possible.
 
2 pages, more comprehensive information on the back.
 

11.06.2021: New version - removed text about betablockers, shortened text about bleeding tendency

25.05.2021: Added other language versions: Arabic, Lithuanian, Polish, Romanian, Somali, Tigrinja, Urdu

30.04.2021: Updated version - question and text about pregnancy and breastfeeding.

22.04.2021: Updated versions 

19.04.2021: Updated versions. Removed checklist.

07.04.2021: Updated versions 

25.03.2021: Updated with question about mast cell disease

12.05.2021: Updated list of beta-blockers

16.03.2021: Updated versions 

 

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  • Year: Dec 2020, Feb 2021, Mar 2021, Apr 2021, July 2021
  • By: Norwegian Institute of Public Health