Covid vaccination questionnaire query

I have secured appointments for my 2 Covid vaccinations, and as part of the booking process, downloaded a form questionnaire médical vaccination Covid 19.

Most of it is straightforward but…
The first section (to be completed by the person to b evaccinated) asks for name, first name, social security number, phone number, birth date and age. I’m clearly cut out for form filling as I was able to complete all of those with no problems.
However, there are three further boxes in this section:

  • Etablissement

  • Fonction

  • Service

Before I guess (and get it wrong) does anyone know what I should enter in these three fields?

Thanks for any helpful, sarcastic or incredulous replies :upside_down_face:

This looks like the form for the vaccination of health professionals!

What box did you tick for criteria when you booked? Perhaps yiu selected the over 50 health professionals rather that the over 55 ordinary people?

Thanks for the reply, Jane.

I booked as a member of the public 55+ with no professional reasons. I’ve just checked on Doctolib (where I made my booking) and I’m definitely in the correct category.

I’ll upload a pdf of the form when I’m back at my desk.

We have also just booked ours via Doctolib but there was no requirement to fill in an additional form.


Just got back from my 2nd Jab… like yours… arranged through Doctolib.

I did not complete the health form from the web (this was a suggestion but not mandatory).
Instead, I was given a form on arrival and I completed it then and there.

Personal details on one side (just fill in what applies to you)… and on the reverse there are health questions… disclaimer to sign.

If you have any medical condition, it might be an idea to take your prescription. The resident Doc was pleased (both times) to read through mine… and give the OK to proceed with the huge needle… (only joking, it’s tiny).

Good luck

Thanks, Stella - very reassuring :face_with_raised_eyebrow:

Chris - if you log into your Doctolib account, go to Mes rendez-vous, click on the appointment for your first vaccination, scroll down the page until you come to Documents reçus and the questionnaire may be there. Mine is marked for Limousin so it’s possible that the requirement only exists in certain departements or regions.

And here’s the first page of the form in question:

The second page is for personal risk factors and information about possible side-effects.
They don’t ask for your address which makes me wonder if that’s what’s meant to go in the Etablissement etc fields…

That doesn’t seem to exist on my appointment page. Ours are in Charente so maybe they are different. Perhaps we will get something to fill in when we get there.

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Don’t forget to take your own pen… (they do have them to hand, but being prepared is better)

by giving your social security number (off of your CVitale) they will get whatever extra info they need.

If you’re really not sure… don’t fill in the form. As I have said, it is not mandatory at this stage.
You can complete one on the day and there will be someone available to answer any query you have at that time.

OH had his jabs at a completely different place (other end of the planet) … and his form was completed by a receptionist and he signed it off…


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Thanks all. I’ll fill the obvious bits and leave the 3 dubious fields as a puzzle.
I’ll report back after the rendezvous with the solution!

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Absolutely fine I reckon.

At my appt place, there were tables where folk sat and completed the form they had been given on entering … so I’m sure you won’t have any trouble… you won’t be alone.

Taking your own pen is a good idea, although I watched as pens, tables and chairs were wiped down after every use. Very impressed with the care shown by all the workforce and they were friendly and helpful.

I had an early appointment and was (perhaps) the only English person so far, this morning, as each time my name was checked against a list… “Oh… Engleesh…” with a questioning laugh.

As I say, very helpful, very careful… excellent all round.

Just a thought. they called folk inside well in advance of the time-slot… so that paperwork etc could be gone through… so don’t arrive “on the dot”… unless you are specifically asked to.

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As all the centres de vaccination are run by different hospitals/agencies, they each have their own form. It’s issued by the centre and not doctolib but the doctolib emails include the wording/links the centres given them.

The forms we were asked to bring were one page with personal stuff on the top (no addess, just name, DOB , social security no and phone/email)
Under that there was a box to tick as to whether we were medics or general public and then there were a very few questions, including whether you have allergies and whether you are right or left handed (so they know the job the other arm)
The doctor repeated all the questions when we got there anyway, and added a few of his own.

As Stella said, they have forms on hand in any case when you arrive. Do take your current prescriptions though - they are particularly bothered about anti-coagulants.

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I’ll second Stella on arriving early - we were actually told to arrive 15 minutes early

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At any rendezvous I am always identified as Anglais long before I open my mouth thanks to my lifelong habit of always arriving very, very early!

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My MT did mine, asked a couple of questions , any allergies, am I pregnant…


Well, you never know these days. :slight_smile:

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We got our first vaccinations in Chauvigny (86) last week booked on doctolib. Arrived at the centre, waited outside until appointment time, all forms completed inside (with carte vitale or SS no) at first desk, next desk, temperature checked, and health questions asked, and which arm you want it in, next desk doctor for injection, next desk doctor checking all ok and issue certificate, wait 15 mins then leave…simples

Thanks, Peter - very reassuring.
But does anyone know what:

  • Etablissement
  • Fonction
  • Service

I really do think these questions are specific for health professionals…
establishment = name of hospital/health centre/care home etc

function = doctor, nurse, pompier,

Service = cleaning, a&e, surgery etc

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