Yellow fever Pre-Vaccination Screening Checklist and Privacy Consent Form

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Name		Date of birth
Phone number	(Home) (Mobile)	Sex	□Male □Female

Question	Answer
Are you sick today? If yes, please describe your symptom(s). ( )	□ Yes	□ No
Have you ever had any allergic reactions such as hives or rash after having taking medication, eating food (including eggs, chicken, and gelatin), or being vaccinated?	□ Yes	□ No
Have you ever had any adverse reaction to any vaccine in the past? If yes, please specify the vaccination(s). ( )	□ Yes	□ No
Have you been vaccinated in the past month? If yes, please specify the vaccination(s). ( )	□ Yes	□ No
In the last month, have you ever had any cramps?	□ Yes	□ No
Have you ever been diagnosed with or treated for birth defects, asthma or a lung disorder, heart disease, liver disease, diabetes or an endocrine disorder, or a blood disorder? If yes, please specify what you were treated for. ( )	□ Yes	□ No
Do you have cancer, leukemia or any other immunological disorders? If yes, please describe the disease(s). ( )	□ Yes	□ No
In the past three months, have you received any steroids, anti-cancer drugs, or radiation treatment?	□ Yes	□ No
In the past year, have you received any blood transfusions or immunoglobulin therapy?	□ Yes	□ No
(For women only) Are you currently pregnant or planning to get pregnant in the next month?	□ Yes	□ No
Consent to the handling of personal information for vaccination	Answer
Collection and use of personal information I hereby provide consent to the following terms of collection and use of my personal information for vaccination conducted by the National Quarantine Station pursuant to Articles 15 and 23 of the Personal Information Protection Act: □ Purposes of the collection and use of personal information: Sharing information between healthcare institutions in case of an adverse event after vaccination □ Sensitive information items: Sensitive information (health information), phone number (home/mobile) □ Retention and use period: Follows the period defined under applicable laws	□ Yes	□ No
Provision of personal information I hereby agree that the National Quarantine Station may share my personal information according to Articles 17 and 23 of the Personal Information Protection Act for the following: □ Purposes of providing personal information: Sharing information between healthcare institutions in case of an adverse event after vaccination □ Institutions to be provided with personal information: Applicable healthcare institutions, Korea Centers for Disease Control and Prevention □ Personal information items and the period of their retention and use: Same as above in "collection and use of personal information"	□ Yes	□ No
I hereby agree to receiving this vaccination after I have been pre-checked and fully informed about potential adverse effects. Vaccinee (legal representative/guardian) name: (Signature) Relationship with the vaccinee: Month Day, Year

※ You have the right to provide no consent to the handling of personal information for vaccination. If you do not provide consent, however, it may limit your ability to receive a vaccination and the issuance of a certificate thereof.

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Persons who cannot be vaccinated

① Infants less than 9 months old

※ Those 60 years or older  must give their voluntary consent due to the small chance of an adverse event after vaccination.

② Pregnant women and breastfeeding mothers

③ Persons hypersensitive to eggs, chicken, and gelatine

④ Persons with a severe fever (those whose body temperature is 38℃ or above)

⑤  Persons who have a history of thymus disease, or persons with congenital or acquired immune malfunction (e.g., acquired immunodeficiency syndrome (AIDS))

※ Persons infected with HIV may be vaccinated for yellow fever if they do not show AIDS, or there is an instruction by the physician.

⑥  Persons who have had any serious allergic reaction (anaphylaxis) to yellow fever vaccination

⑦ Patients with hereditary fructose intolerance

Things to note post-vaccination

① No blood donations are allowed for 14 days after vaccination.

② No alcohol is allowed for 3 days after vaccination.

③  Neither the sauna nor a full bath is allowed for 3 days after vaccination. (But showers are permitted.)

④ Some may have a slight fever, headache, fatigue (muscle pain), or pain at the injection site for 3 to 14 days following the vaccination. In rare cases, some may experience an adverse effect (severe and continued vomiting or rash; skin tingling or numbness; severe headache; shortness of breath; cramps; coma; increased acidity in the blood; disintegration of muscle or liver cells; decreased lymphocytes and platelets; or renal failure). Even if it is rare, multiple organ dysfunction syndrome (life-threatening) and allergic reactions may occur, as may serious side effects in the nervous system (meningoencephalitis; Guillain-Barre Syndrome; or acute disseminated encephalomyelitis). (It may occur even one month after vaccination). If you experience any of these symptoms, please contact the vaccination authorities.

Vaccinator (healthcare provider) form
Body temperature: ℃	Notable findings upon check-up:
I have fully informed the vaccinee about things to follow post-vaccination and any possible adverse effects.		□Yes □No
I have fully informed the vaccinee that he or she should "stay for 20 to 30 minutes at the vaccination institution to observe any adverse effects."		□Yes □No
Vaccinator (healthcare provider) name: (Signature)