[Form No. 1]
                           Immunization Screening Questionnaire
 To ensure a safe vaccination, please read the following questions carefully and complete the form by selecting the
                    appropriate response as either the Patient, Parent, or Legal Guardian.
                                         Personal Information of Vaccine Recipient
    Full Name                                    Resident Registration Number                    -             (☐ Male ☐ Female)
  Date of Birth                                  Foreign Registration Number
 (YYYY.MM.DD)                                           (if applicable)                          -             (☐ Male ☐ Female)
 Contact Number (Home)                             (Mobile)                                        Weight           kg
                    Consent for Collection and Use of Personal Information                           Identity Verification ☑
In accordance with Article 32 of the Infectious Disease Control and Prevention Act and Article 32-3 of its Enforcement
 Decree, we collect personal and sensitive information, including your Resdent Registration Number. The details of the
 collection and use are as follows:
  ① Purpose of Collection and Use: To provide notifications regarding upcoming vaccinations and completion status / To
     monitor adverse events following immunization (AEFI) through SMS and mobile applications
  ② Collected Information: Personal data (including sensitive information and Resident Registration Number) / Home and
      mobile phone numbers
  ③ Retention period: 5 years
 I hereby consent to the verification of my (or my child’s) vaccination records through the
Immunization Registry Information System (IRIS) under Article 26-2 of the Infectious Disease
Control and Prevention Act.                                                                            ☐ Yes ☐ No
  * If you do not consent, healthcare providers may request your vaccination history in writing,
     and you must comply unless there are special circumstances.
 I agree to receive SMS and mobile app notifications regarding upcoming vaccinations and
completion status.                                                                                     ☐ Yes ☐ No
  * If you do not consent, you will not receive updates on vaccination schedule updates.
 I agree to receive SMS and mobile app notifications regarding the monitoring of adverse events
following immunization (AEFI).
for monitoring adverse events following immunization (AEFI).                                           ☐ Yes ☐ No
  * If you do not consent, you will not receive notifications related to AEFI monitoring.
                          Pre-Immunization Screening Checklist                                                  Identity Verification ☑
                (To be completed by the Patient, Parent, or Legal Guardian)
 1. Have you received any vaccinations in the past month? If yes, please specify the vaccine. (                   ☐ Yes ☐ No
                                                                                     )
 2. Have you ever experienced adverse reactions following a vaccination that required medical                     ☐ Yes ☐ No
      treatment? If yes, please specify the vaccine. (                                   )
 3. Are you feeling unwell today? If yes, please describe your symptoms.                                          ☐ Yes ☐ No
      (                                                                                            )
 4. (For female recipients only) Are you currently pregnant or planning to become pregnant within the next        ☐ Yes ☐ No
    month?
 5. Have you ever had an allergic reaction (such as hives, rash, anaphylactic shock, breathing difficulties,      ☐ Yes ☐ No
     loss of consciousness, or swelling of the lips/month) to medications, food (e.g., eggs), or vaccines?
 6. Have you ever been diagnosed with cancer, leukemia, or an immune system disorder? If yes,                     ☐ Yes      ☐ No
    please specify. (                                                                      )
 7. In the past therr months, have you received steroids, chemotherapy, or radiation therapy?                     ☐ Yes      ☐ No
 8. In the past year, have you received a blood transfusion or immunoglobulin treatment?                          ☐ Yes      ☐ No
 9. (For COVID-19 vaccination) Do you have a blood clotting disorder or are you currently taking                  ☐ Yes      ☐ No
    anticoagulants? If yes, please specify the condition or medication. (                 )
 10. Have you ever experienced seizures or neurological conditions (e.g., Guillain-Barré                          ☐ Yes ☐ No
      Syndrome)?
 11. Have you ever been diagnosed with or treatd for ay congenital anomalies, asthma, lung
     disease, cardiovascular disease, kidney disease, liver disease, endocrine disorders (e.g.,                   ☐ Yes ☐ No
     diabetes), or blood disorders (excluding blood clotting disorders)? If yes, please specify.
     (                                                            )

 Acknowledgement & Consent for Vaccination
 I confirm that I have received an explanation regarding my (or my child’s) medical examination and potential adverse
 events following immunization (AEFI). I consent to the administration of the vaccination.
 Patient, Parent, or Legal Guardian Name:                                             (Signature)
 Relationship to Vaccine recipient:
 * National Registration Number of Legal Guardian (if your child’s birth        Date(yyyy/mm/dd):
   has not yet been registered):             -
        Physician’s Pre-Vaccination Screening Results (To be completed by the physician)                                  Check ☑
                                    The recipient has been informed of potential adverse reactions following
 Body Temperature:            ℃
                                    immunization (AEFI).                                                                      ☐
 The recipient has been advised to remain at the medical institution for 20-30 minutes for post-vaccination
 observation.                                                                                                                 ☐
 Results of history-taking:
 Based on the patient’s history and physical examination, the recipient is cleared for vaccination.
 Physician’s Name:                                                               (Signature)

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