Cholera Pre-Vaccination Screening Checklist and Privacy Consent Form

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

※ 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.

Question	Answer
Are you sick today (particularly stomach or gastrointestinal discomfort) 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? If yes, please describe the symptom(s). ( )	□ 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 hospitalized in the past month? If yes, please specify the reason(s). ( )	□ 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

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Persons who cannot be vaccinated

① Persons with a severe fever (those whose body temperature is 38℃ or above)

② Consultation is required before vaccination if you have taken another medication or are currently on medication.

※ While pregnant women and breastfeeding mothers may be vaccinated, consultation with the physician or pharmacist is required.

③ Persons with an acute gastrointestinal disorder or a fever

④ Persons allergic to oral cholera vaccination

Things to note post-vaccination

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

② No food, beverage, or other medication is allowed for 1 hour before and after vaccination.

③ No alcohol is allowed for 3 days after vaccination.

④ Some may experience gastrointestinal symptoms (stomach pain, stomach cramps, or diarrhea). In extremely rare cases, some may experience severe fever, systemic discomfort, nausea, vomiting, loss of appetite, a runny nose, cough, or dizziness. If you experience any of these symptoms, please contact vaccination authorities.

Things to note for cholera vaccination

① Young children ages 6 or older and adults: Basic vaccination 2 times, at an interval of 1 to 6 weeks. Then, make sure to get re-vaccinated again within 2 years for continued protection.

② Young children ages 2 to 5: Basic vaccination 3 times, at the interval of 1 to 6 weeks. Then, make sure to get re-vaccinated again within 6 months for continued protection.

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)