Form/Template Jan 7, 2022 DHA Form 236: Pediatric (5-11 years) COVID-19 Vaccine Screening and Immunization Documentation, v12 .PDF | 61.96 KB This form is used to determine if the COVID-19 vaccine can be administered to the pediatric patient. (Version 12, May 2023) Recommended Content COVID-19 Vaccine COVID-19 Children's Health Immunization Healthcare Division