The information below is shared by CPESN Pharmacies and CPESN Network Leaders across the country.

Files have not been thoroughly vetted with The CDC Guidelines.

Please utilize at your discretion. Certain aspects may differ from State to State.

Patient Awareness/ Patient Education Resources

Patient Awareness about COVID-19 Vaccine Flyers [updated 12.31.2020]

• When the pharmacy staff is educated about the vaccine, post a flyer for your patients and people within your community so that they know your pharmacy is a vaccine administration site.

• Click below to access the flyers.

  • Flyer #1 and Flyer #2: Consider posting one of these on your drive-through window or your entry door into the pharmacy. 

  • Flyer #3: Patient Awareness Flyer about the COVID-19 Vaccine Safety and who receives it.

    • Consider customizing to include which phase that we are currently in​.
      • This can be done by using a PDF editor, copying and pasting the text in a word document.
    • On the bottom left of Page 2, there are (possibly) invisible text boxes that you can add text for patients to get the most up-to-date information. Examples include:
      • "In order to receive the most up-to-date information from [Insert CPESN Pharmacy Name], follow our Facebook Page [insert page name] or visit our website [insert website address].
      • May also consider adding an IVR option for vaccine information and someone at the pharmacy updates the recording there.
    • May print front and back instead of 2 pages.

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Flyer #1 

Flyer #2

Flyer #3

Ensure your processes are in place for triaging questions & scheduling appointments [updated 12.31.2020]

• If this does not occur, the regular pharmacy workflow will back-up quickly due to strained resources.

• Best Practice #1: Determine and implement your appointment scheduling software. Be sure to test it out before going live with it.

• Best Practice #2: Provide the process/steps for the patients (i.e., healthcare providers) to schedule an appointment (preference – click here to complete the form vs. calling the pharmacy to schedule an appointment).

• Best Practice #3: Set up your IVR Phone System with a Message (consider an option / person to triage these questions to within the pharmacy)

• Click here to view.

  • SMP Pharmacy provides patients with a checklist for 1) requesting a vaccine, 2) scheduling appointment, 3) preparing for the appointment, 4) what to do at the time of appointment, and 5) what to do after the appointment.

  • Best Practice: Have patients check in when they arrive by using the Mobile Check In App (Click here to be directed to the Apple App Store; cost is reasonable and can be used for other services)

• Best Practice: Consider creating something similar for your patients in order to provide more clarity in an effort to decrease patient questions and improve patient guidance.

Checklist for patients as they prepare to get the vaccine [updated 1.18.2021]

Update your website to provide Patients with COVID-19 Vaccine Resources 

[updated 1.18.2021]

• Click here to view SMP Pharmacy's website!​

Vaccine Distribution / Administration Processes

Process/plan for a large vaccine clinic with numerous resources & how to apply for a smaller vaccine clinic [updated 1.13.2021]

• Click here to download the Word document that you can repurpose for your needs. Includes process considerations from pre-clinic through clinic patient flow plan

  • Plan/Process was utilizing for a clinic size of 200+ vaccines over about 4 hours with numerous human resources.

• Guidance for applying to smaller staffs or smaller vaccine clinics:

  • You could decrease the overall number of staff per station and/or consolidate the greeter and registration positions down to one station. And with less people in a smaller space you may not need a person dedicated to post vaccination observation.  The dose preparation piece also depends on which product is being utilized as we have used 1 person at some of our Moderna clinics, but with the Pfizer vaccine we utilize at least 2 (sometimes all people staffing a clinic will start by diluting a Pfizer vial and then the dose preparation people only have to draw up doses for a good portion of the clinic).

Tips for Managing COVID-19 Vaccine Distribution [updated 1.13.2021]

• Click here to view CPESN AR document (CPESN AR pharmacies are currently participating in Phase 1 at the State Level.

  • Includes​ General Tips and Expectations, Time Saving Tips, Example Workflow Process (see image below) and Tips

Action Items for Before and After Receiving Vaccines [updated 1.13.2021]

• Click here to review the one-pager.

  • This is Arkansas specific for the email contact, so please do not email this contact for your Call the Shots Training, unless you are involved in the vaccine rollout in Phase 1 within CPESN AR.​

In order to encourage social distancing, have patients check-in for their appointment using an App [updated 1.18.2021]

• Step 1: Create an account for the Mobile Check-In App (Click here to be directed to the Apple App Store; cost is reasonable and can be used for other services)

• Step 2: Inform patients to download the Mobile Check In app via the App Store [My Mobile Check In] or Google Play [Mobile Check In] on their smartphone. This will allow a patient to “Check In” to the pharmacy when they arrive in the parking parking lot.

• Step 3: When patients arrives and. checks in (must be less than 1/4 mile from pharmacy to check-in), the staff can text when ready for the patient's appointment.

  • If the patient does not have a smart phone, provide the pharmacy's phone number with a specific extension to dial.

Triaging Patients for the Appropriate COVID-19 Vaccine Phase

Insert "conditions" into your online consent form / appointment scheduler to help determine if the patient qualifies for the current phase [updated 1.18.2021]

• Example:  if we are in phase 1A and someone selects "person with chronic condition" or a choice that doesn't meet current phase; we can "hide" the rest of the form so the patient is unable to complete & schedule an appt. 

• "This has helped us SO much with preventing people who don't qualify filling out forms & clogging up appt times and greatly reduced staff time in making calls & canceling appointments." - Cheri Schmit 

COVID-19 Vaccine Consent Forms

Printable Consent Forms [updated 1.10.2021]

• Edit and make specific to your community pharmacy

  • Add your logo and pharmacy address / phone number.

  • The Word versions are available for you to edit to personalize and maintain an updated version.​

  • If form items are missing which are required for your State's IIS, add them.

• Utilize the "Pharmacy Use for Insurance Information" Box on page 2 to write in the appropriate insurance ​information for the Prescription and/or Medical Insurance.

• Useful for those patients / community members that may not have many technology skills.​

Click here to download the Word version of the general COVID-19 Vaccine Consent Form (images above)

Click here to download the Word version of the Moderna COVID-19 Vaccine Consent Form (Contains the Link to the Moderna EUA Fact Sheet)

Click here to download the Word version of the Pfizer COVID-19 Vaccine Consent Form (Contains the Link to the Pfizer EUA Fact Sheet)

Click here to download the Word version of the combined Janssen/Moderna/Pfizer COVID-19 Vaccine Consent Form 

Online Consent Forms Available via JotForm (HIPAA Compliant) [updated 1.10.2021]

• The Moderna COVID-19 Vaccine Consent Form listed above has been added to JotForm for pharmacies to utilize and customize.

  • The Word Document was loaded onto JotForm as a PDF and the patient facing online consent form maps to the PDF. Example is listed below.

  • These developed Consent Forms that can be utilized at your pharmacy can be customized after you have a JotForm Account. There are 2 versions of this online Consent Form Available

    1. Online Consent Form Only​

    2. Online Consent Form with Appointment Scheduling

  • Patient has the ability to download the Moderna Fact Sheet at the end and download the completed PDF (as seen below).

    • May encourage patients to bring this completed form in with them or may print it on their behalf (directions in stepwise document). 

• Stepwise Approach to utilizing this templated Online Consent Form within JotForm​​​​

  • Click here for a One-Page Step​-by-Step Approach to utilizing this form and learn best practices in utilizing the Online COVID-19 Vaccine Consent Form.

• Click here to view an example of the form after a patient completes online

  • You may download by viewing submissions by selecting "PDF Submissions"​

  • Then edit the Pharmacy Use Only sections once the patient receives the vaccine.

Online Consent Forms Available via JotForm (HIPAA Compliant) [updated 1.13.2021]

• Hartzell's Pharmacy has COVID-19 Screening and COVID-19 Vaccine Consent Templates available. 

  • Note that Hartzell's is located in PA. Make specific to your State​ and follow your State's phased guidance with consideration of the ACIP recommendations when necessary for who to prioritize for the vaccine.

  • How to Access: Search "PA Pharmacy" to find these templates, upload to your HIPAA-Compliant JotForm Account and modify as you need for your pharmacy.

    • Click here to access JotForm Template's Search Function​

Assistance with Setting up Online Consent Forms & Appointment Software [updated 1.18.2021]

• If you need assistance with setup, scheduling, or form creation, GRX Marketing is available to assist at a rate of $50/hour. Average time to build forms is 1-3 hours per form. Click here to view the flyer.

  • Also, can help set up forms based on local/state/federal guidance for appropriate COVID-19 vaccine phase designation for a patient.​

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• PrescribeWellness offers a consent and scheduling product that is free for anyone that has all of their solutions (CompleteCare) and they have an option for pharmacies that are not PrescribeWellness users. Click here to view the flyer.

Consent Forms for COVID-19 Vaccine in Other Languages [updated 1.27.2021]

• Spanish version for Moderna: Click here to download the Word version.

• Spanish version for a combined Pfizer/Moderna Consent: Click here to download the Word version.

• Spanish version for a combined Pfizer/Moderna/Janssen Consent: Click here to download the Word version.

• Vietnamese version for Moderna: Click here to download the Word version.

EUAs / Fact Sheets for the Vaccine

Providing Patients with Post Vaccine Information (Vaccine Fact Sheet, Appointment Scheduling, and V-SAFE registration) [updated 1.31.2021]

• Rather than printing lots of Fact Sheets for patients, Kelley-Ross Pharmacy has developed a quarter page “Post Vaccine Information Sheet” for patients.

  • It provides patients with 3 QR codes to access the Vaccine Fact Sheet, their appointment website to schedule their next dose, and registration for V-SAFE.

  • The vaccine administrator notes the time the patient is okay to leave the pharmacy after monitoring and the earliest date the patient can receive their second dose.

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• Step 1: Download the PowerPoint Template created by Kelley-Ross Pharmacy: Click here

• Step 2: Customize for your pharmacy

  • Add your pharmacy's logo

  • Edit to provide the appropriate vaccine QR code (the example has Pfizer vaccine's Fact Sheet QR code)

    • The Moderna Vaccine QR code can be found on page 4 of the Moderna Fact Sheet: Click here​.

    • For all other QR codes view the Fact Sheets for the Vaccines: Click here for the most updated approved EUA Fact Sheets.

  • Add a QR code to allow the patient to go to the pharmacy's appointment website (if you do not have this; remove from flyer)

    • ​You can create a free QR code with or without your logo using this website: Click here.  

• Step 3: Provide the quarter-page to the patients after ensuring they have a smart phone for accessing the QR codes.​

Technology Resources

Utilizing eCare Plans in PioneerRx for Second Dose Reminders (for the Pharmacy) [updated 2.19.2021]

• Pharmacist Matt Wlodyga with Chet Johnson Drug has created an automated care plan trigger for second dose reminders. Click here for the instructions​.

Workflow for a Vaccination Clinic

Leverage the experience from 20 COVID-19 Vaccination Clinics [updated 2.21.2021]

• John DeJames with Value Drug Company developed this highly efficient workflow and has assisted 20 clinics. Click here for the clinic workflow​.

Anaphylaxis Protocol and SOP for COVID Vaccines

Anaphylaxis Protocol [updated 2.21.2021]

• Best Value Pharmacies developed this anaphylaxis protocol - See Section J. Click here for the standard operating procedure.​

Emergency Box for COVID Allergic Reactions [updated 2.21.2021]

• Pharmacist Becky Hamilton with Lacey’s LTC Pharmacy created an Emergency Box. Click here to access it.

USP Storage and Handling Summaries

CDC Vaccine Storage and Handling Official Toolkit [updated 2.21.2021]

• Click here for the updated storage and handling toolkit (from February 5, 2021).​

• From: USP RE: Moderna Storage Containers

  • There appears to be greater need for inflow of the containers for redistribution efforts (as you know, far more settings now qualify for vaccines and it’s being sent to a greater number of places than before), hence the new ask to ensure sites are returning the shipping containers for Moderna to keep things going very smoothly and quickly. So the ask would be to schedule a pick up via the UPS if you don’t have a regular UPS stop in eligible pharmacies. Per the label, the UPS drivers can just pick this up if they make regular stops at your store without any paperwork needed or need to ‘schedule’ the pick up. They asked that the shippers be returned as soon as possible when a UPS pickup can take place. 

  • Both of the frozen products have a return program for their thermal shipping containers.

    • Pfizer needs their data loggers returned with the box.

    • Moderna/McKesson only needs the box.

  •  Both arrive with a printed return label so it is no cost to the provider site. Both include a pamphlet describing how to return their box.

HIPAA Attestation for Volunteers

• Click here for the Microsoft Word version that you can edit and customize to meet your pharmacy's needs.

• Click here for tips on running clinics from Hesston Pharmacy.