They help us to know which pages are the most and least popular and see how visitors move around the site. (Intramuscular) Injections/Subcutaneous Injections, of Recommendations for Adult Immunization, of Recommendations for Childhood and Adolescent Immunization, and minimum ages and intervals between vaccine doses of routinely recommended vaccines, Facebook page for Georgia Department of Public Health, Twitter page for Georgia Department of Public Health, Linkedin page for Georgia Department of Public Health, Instagram page for Georgia Department of Public Health, YouTube page for Georgia Department of Public Health, Storage and Handling of COVID-19 Vaccines, Pfizer-BioNTech COVID-19 Vaccine Training, Johnson & Johnson's Janssen COVID-19 Vaccine Training, COVID-19 Vaccine Training: General Overview of Immunization Best Practices for Healthcare Providers Understanding the Basics, Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines Currently Authorized in the United States, Interim Considerations: Preparing for the Potential Management of Anaphylaxis After COVID-19 Vaccination, COVID-19 Interim Guidance for Immunization Services During the COVID-19 Pandemic, Clinical Considerations for COVID-19 Vaccination, Pfizers COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine, Modernas COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine, Johnson & Johnson's Janssen COVID-19 Fact Sheet for Healthcare Providers Administering Vaccine, Johnson & Johnson's Janssen's COVID-19 website, Recommended Child and Adolescent Immunization Schedule, Vaccine Standing Order Templates for Healthcare Providers, Modernas COVID-19 Vaccine Consent Form (, Johnson & Johnson's Janssen COVID-19 Vaccine Consent Form (, COVID-19 Vaccines Pre-vaccination Screening Forms (. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. The site is secure. Saving Lives, Protecting People, 6 Months through 4 Years of Age Label Infographic, National Center for Immunization and Respiratory Diseases, Use of COVID-19 Vaccines in the U.S.: Appendices, FAQs for the Interim Clinical Considerations, Myocarditis and Pericarditis Considerations, Jurisdictions: Vaccinating Older Adults and People with Disabilities, Vaccination Sites: Vaccinating Older Adults and People with Disabilities, Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities, Vaccines for Children Program vs. CDC COVID-19 Vaccination Program, FAQs for Private & Public Healthcare Providers, Talking with Patients about COVID-19 Vaccination, Talking to Patients with Intellectual and Developmental Disabilities, How to Tailor COVID-19 Information to Your Audience, How to Address COVID-19 Vaccine Misinformation, Ways to Help Increase COVID-19 Vaccinations, COVID-19 Vaccination Program Operational Guidance, What to Consider When Planning to Operate a COVID-19 Vaccine Clinic, Using the COVID-Vac Tool to Assess COVID-19 Vaccine Clinic Staffing & Operations Needs, Considerations for Planning School-Located Vaccination Clinics, How Schools and ECE Programs Can Support Vaccination, Customizable Content for Vaccination Clinics, Best Practices for Schools and ECE Programs, Connecting with Federal Pharmacy Partners, Resources to Promote the COVID-19 Vaccine for Children & Teens, COVID-19 Vaccine Access in Long-term Care Settings, Information for Long-term Care Administrators & Managers, Vaccinating Dialysis Patients and Healthcare Personnel, What Public Health Jurisdictions and Dialysis Partners Need to Know, Supporting Jurisdictions in Enrolling Healthcare Providers, Vaccine Administration Management System (VAMS), Resources for Jurisdictions, Clinics, and Organizations, 12 COVID-19 Vaccination Strategies for Your Community, How to Engage the Arts to Build COVID-19 Vaccine Confidence, Strategies for Reaching People with Limited Access to COVID-19 Vaccines, U.S. Department of Health & Human Services. The U.S. Food and Drug Administration (FDA) has authorized the emergency use of certain COVID-19 Vaccines to prevent COVID-19 in individuals 6 months through 17 years under an State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. Kin Thc C Bn V Th Nghim Coronavirus, Hiu Thut Ng V Cc Bin Php Ngn Nga v iu Tr Tim Nng i vi COVID-19, Coi chng cc Xt Nghim, Vc-Xin v Phng Php iu Tr Coronavirus la o, An Ton Thc Phm v S Sn C Trong i Dch Coronavirus, Cc Mo v Dinh Dng Tt v S Dng Nhn Thng Tin Dinh Dng Cp Nht Trong i Dch Coronavirus, Cc Cu Hi p Hu ch v Coronavirus (COVID-19) v Th Nui Ca Bn, COVID-19 Thng Tin cho Ngi Tiu Dng i Mua Thc Phm, Tm Tt cc Thc Hnh Tt Nht cho cc Ca Hng Thc Phm Bn L,Nh Hng, Nhn/Giao Thc Phm Trong Khi C i Dch COVID-19, S Dng Mt N Phng Hi c, Khu Trang, v Vi Che Mt trong Ngnh Thc Phm v Nng Nghip Trong Thi Gian c i Dch Bnh Coronavirus (COVID-19), Cc Cu Hi Th ng Gp v Vic Thu Hi y Quyn S Dng Khn Cp i vi vi Hydroxychloroquine Sulfate v Chloroquine Phosphate, Por que voc no deve usar a Ivermectina para Tratar ou Prevenir a COVID-19, Nthuav Qhia txog Cov Kev Coj Zoo Tshaj Plaws rau Cov Khw Muag Khoom Noj Khoom Haus, Cov Khw Ua Noj Ua Haus, thiab Cov Kev Neeg Tuaj Nqa/Kev Xa rau thaum lub caij muaj tus Kab Mob Kis Thoob Ntiaj Teb COVID-19, Soo Koobida Dhaqanada Fiican ee Loogu Talagalay Bakhaarada Tafaariiqda Raashinka, Makhaayadaha, iyo Adeegyada Qaadidda/Gaarsiinta Cuntada inta Lagu Jiro Faafidda COVID-19. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. La mayora de las personas que han tenido estas hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- Thank you for taking the time to confirm your preferences. 401 0 obj You can review and change the way we collect information below. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. If you would like a response please use the enquiriesform instead. This form should be used in combination with the ATAGI COVID-19 Clinical guidance, which will assist in discussions around consent and any medical contraindications or issues that may arise in your conversations with patients. Suggestions are presented as an open option list only when they are available. Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. The Pfizer- BioNTech COVID-19 Vaccine is approved by the U.S. Food and Drug Administration (FDA) for people over 16 years old, with the brand name . This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. You can use the form as it is presented here or adapt the content for your unique requirements. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). English Description: This consent form is not mandatory. Please limit your input to 500 characters. We take your privacy seriously. \r\rCS321629E\rJanuary, 2023 94 [Content_Types].xml ( Qo0_Qn P= {IW/$mPtA{:gq]q)[(QdR(*,_-nr!WbC?J%FRc5eTZK Z \|Z5/'ACTSUBV.lfXVAxN)qU7\m8+$kQ*QC5OwU 5[]9xen2&a'$0H0_At9HBd:'u )"dAza|DQL(-I. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. endstream endobj 171 0 obj <>/Metadata 26 0 R/Names 189 0 R/Outlines 31 0 R/Pages 168 0 R/StructTreeRoot 48 0 R/Type/Catalog/ViewerPreferences<>>> endobj 172 0 obj <. Cookies used to make website functionality more relevant to you. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. endobj I reviewed this consent form and have read and understand the "Fact . Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. Food and Drug Administration. Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. Vaccinating children Complete and submit reports to VAERS online. ( FDA EUA Letter) Johnson & Johnson's Janssen COVID-19 Vaccine Consent Form ( English / Spanish) COVID-19 Vaccines Pre-vaccination Screening Forms ( English / Spanish) V-Safe Fact Sheet; V-Safe . Thank you for your website feedback! Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> The recipients health condition or recommendations for vaccination may change from one visit to the next. 2. Help us improve health.gov.au. <>stream Read and print an information sheet about the use of VISs, including recordkeeping requirements. This page is located more than 3 levels deep within a topic. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Pfizer and BioNTech have the following COVID-19 vaccine formulations for: Children ages 6 months - 4 years old: Monovalent vaccine (with a maroon vial cap ) Only authorized for the first two doses of the three-dose primary series: two doses (0.2 mL), at least three to eight weeks apart. 0 187 0 obj <>/Filter/FlateDecode/ID[<3C4CB76F7817EC43BD8A3A51D7CF58C8>]/Index[170 28]/Info 169 0 R/Length 90/Prev 97852/Root 171 0 R/Size 198/Type/XRef/W[1 3 1]>>stream Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. . (Check back as we will continue to. Administration of Pfizer-BioNTech COVID-19 Vaccines Administration Overview Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? How you know. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. You will be subject to the destination website's privacy policy when you follow the link. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. If you need assistance, please contact the Department of Public Health. More about Pfizer-BioNTech COVID-19 Vaccines While consent before vaccination is mandatory in Australia, written consent is not required. A patient consent form for COVID-19 vaccination. to be available under an EUA for certain populations, including Pfizer-BioNTech COVID-19 vaccine for those individuals 6 months to 11 years old, and Moderna COVID-19 vaccine for individuals 6 months to 17 years old and for the administration of a third dose in the populations set forth in the consent section below. Complete and submit reports to VAERS online. New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes Share sensitive information only on official, secure websites. For further assistance with reporting to VAERS, call 1-800-822-7967. Address if different from above . They help us to know which pages are the most and least popular and see how visitors move around the site. Fecha These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Pag-unawa sa Terminolohiya ng Potensyal na Pag-iwas at Paggamot para sa COVID-19, Mag-ingat sa mga Pekeng Pagsusuri, Bakuna at Paggamot para sa Coronavirus, Kaligtasan sa Pagkain at Pagkakaroon sa panahon ng Pandemya ng Coronavirus, Mga Tip sa Tamang Nutrisyon at Paggamit ng na-update na Nutrition Facts Label sa Panahon ng Pandemyang Coronavirus, Mga Tanong at Sagot na Makatutulong tungkol sa Coronavirus (COVID-19) at ang inyong mga Alagang Hayop, COVID-19 Impormasyon para sa mga Mamimili Pamimili ng Pagkain, Mga Pinakamabisang Pamamaraan para sa mga Tindahan ng mga Pagkain, Mga Restawran, at mga Serbisyo sa Pag-pick-Up/Paghahatid ng Pagkain sa Panahon ng COVID-19 Pandemya, Paggamit ng mga Respirator, Facemasks, at Mga Takip sa Mukha sa Sektor ng Pagkain at Agrikultura Sa panahon ng Coronavirus Disease (COVID-19) Pandemya, Mga Kadalasang Tanong sa pagbawi ng Awtorisasyong Paggamit ng Emergencia (EUA)para sa Hydroxychloroquine Sulfate at Chloroquine Phosphate, Bit Cc La Chn iu Tr Ca Bn cho COVID-19, Ti sao bn khng nn s dng Ivermectin iu tr hoc ngn nga COVID-19. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. endobj Before sharing sensitive or personal information, make sure youre on an official state website. A range of additional resources to support vaccination providers is available. Pfizer-BioNTech COVID-19 Vaccine Consent Form Sample for Minors COVID-19 Vaccine Consent For Individuals Under 18 Years of Age Section 1: Information about the child to receive a COVID-19 Vaccine (please print): Child's Name (Last, First, Middle) Date of Birth (mm/dd/yyyy)Age Street AddressCityStateZip Phone Number CAIR Record web form. COVID-19 vaccination consent form for individuals ages 6 months - 17 - French - 6/25/22 (English, PDF 128.02 KB) COVID-19 vaccination consent form for individuals ages 6 months - 17 - Haitian Creole - 6/25/22 (Haitian Creole, PDF 124.25 KB) English Espaol Portugus, Portugal Ting Vit Kriolu di Cabo Verde Polski Research has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19. This product (for ages 12 years and older) is no longer being distributed. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. FDA requires vaccination providers to report vaccine administration errors, serious adverse events, cases of multisystem inflammatory syndrome, and cases of COVID-19 that result in hospitalization or death after administration of COVID-19 vaccine under an EUA. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Consentimiento de vacuna contra la COVID-19. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. You will be subject to the destination website's privacy policy when you follow the link. 402 0 obj <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> If my child or adult conservatee does not have a . Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). . secundarios leves despus de recibir una vacuna contra el COVID-19. %%EOF More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. You can review and change the way we collect information below. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. 170 0 obj <> endobj endstream Did You Know? You will be subject to the destination website's privacy policy when you follow the link. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. %PDF-1.6 % These cookies may also be used for advertising purposes by these third parties. Top-requested sites to log in to services provided by the state. Local, state, and federal government websites often end in .gov. They help us to know which pages are the most and least popular and see how visitors move around the site. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. Section 3: Consent. The feedback will only be used for improving the website. Cookies used to make website functionality more relevant to you. Pre-Vaccination Screening Form: English Spanish; Pfizer. We aim to provide documents in an accessible format. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. %%EOF We take your privacy seriously. Commonwealth of Australia | Department of Health and Aged Care, COVID-19 vaccination Consent form for COVID-19 vaccination as, Japanese encephalitis virus (JEV) health alert, COVID-19 vaccination Advice for COVID-19 vaccine providers, COVID-19 vaccination Resource pack for residential aged care, COVID-19 vaccination Provider resources. Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. You can review and change the way we collect information below. CDC twenty four seven. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Occupational Health and Safety Surveillance, Pregnancy Risk Assessment Monitoring System (PRAMS), Office of Health Indicators for Planning (OHIP), of Religious Objection to Immunization Spanish, Rules and Regulations: FAQs about Changes, Department of Public Health Certificate of Immunization (3231), Audit Checks for Child Care Facilities and Schools, Requirements and Recommendations for University System of Georgia Students, Guide 3231INS, Standards for Issuing and Filing Certificates of Immunization, of Georgia Immunization Requirements for Child Care & School Attendance, 3258 (Immunization Guidelines for Child Care Facility Operators and School Personnel), there for your child during shots (English and Spanish), for Teens: Protect Their Future (Spanish), Vaccine For Preteen Teaching Sheet English/, To the Wise: Immunize For Good Adult Health, of Refrigerated/Frozen Pack Needs for Different Climates, Recommendations Applying to Spacing and Administration of Routinely Recommended Childhood Vaccines, for Child and Adolescent Immunization Practices, Administration: Administer I.M. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. For further assistance with reporting to VAERS, call 1-800-822-7967. Please let us know how we can improve this page. I agree that: 1. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Please remove any contact information or personal data from your feedback. para menores de 18 aos. Why cant they be updated every year? 454 0 obj Vaccination providers should ensure they record that an individual has given their consent for a COVID-19 vaccination according to the requirements of their state/territory. Bivalent vaccine (with a maroon vial cap and different label. A .mass.gov website belongs to an official government organization in Massachusetts. 431 0 obj We are always looking for ways to improve our website. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. The official version of thesetranslations is the English version. Relacin con el menor. CDC twenty four seven. Mass.gov is a registered service mark of the Commonwealth of Massachusetts. Thank you for taking the time to confirm your preferences. The .gov means its official.Federal government websites often end in .gov or .mil. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Each VIS on this website is labeled with the date it was published. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) Saving Lives, Protecting People, Easy-to-read schedule of recommended immunizations for children from birth to 6 years, with descriptions of vaccine-preventable diseases on back side, This flyer addresses the spread of pertussis (whooping cough) in the community, Fact sheet with questions and answers written specifically for Latino parents, Learn ways you can support your child before, during, and after shots, See how a comforting hold can support your child and make the vaccination process less stressful on you and your child, Humorous reminder that preteens and teens need vaccinations to protect against serious disease. Based on evidence of safety and efficacy, the U.S. Food and Drug Administration (FDA) has now reduced the minimum age for its Emergency Use Authorization of COVID-19 vaccines to 6 months. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. An official website of the State of Georgia. These cookies may also be used for advertising purposes by these third parties. %PDF-1.7 % To receive email updates about this page, enter your email address: We take your privacy seriously. V-Safe After Vaccination Health Checker - English PDF. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. DOH COVID-19 Vaccination Consent Form I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age (for Pfizer vaccine consent only); or (c) legally authorized to consent for vaccination for the patient named above. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. You skipped the table of contents section. Direccin si es diferente de la anterior. endobj Thank you for taking the time to confirm your preferences. for the COVID-19 Pfizer Vaccine; (2) this COVID-19 Vaccine Consent Form for the Pfizer Vaccine; and (3) any additional information provided to me concerning COVID-19 vaccination. All information these cookies collect is aggregated and therefore anonymous. endstream endobj startxref These cookies may also be used for advertising purposes by these third parties. COVID-19. hXmo6+""4ulb0VTlKQatz>@I(b 0[T,5L+[b143+p[`B' PLH$_0 G%4]8\:>'51h4{.ju-/>tuZL/rKDXx.Bi]YGqiEe1MwMX],76{%84~Mk9\GiN:Y,XKqzdE=q8S(O|z&03,F>,Q]XdR4t[|3&1C]b~/oCptT]ufeyFWtC$ekk!5~ssrrME7RXA^zSl|:8iFu?%PcB (ac69`ud=VI'. FDA is responding to the novel coronavirus outbreak. If you are being inoculated by CVS, we've included that form below. Find VISs translated into other languages. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . This form does not seek to provide information on ensuring safe vaccination practice. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Both forms must be complete at time of vaccination. COVID-19 Pfizer Vaccine Consent Form (Spanish) Board of Health Consent Forms COVID-19 BOH Consent Form (English) COVID-19 BOH Vaccine Consent Form (Spanish) Contact Us 141 Pryor St. SW Atlanta, GA 30303 404-612-4000 customerservice@ . Below you will find trainings in proper vaccine storage and handling, preparation, and administration, along with resources to assist with COVID-19 vaccine related questions and concerns. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Cookies used to make website functionality more relevant to you. <>stream Name (Last, First, Middle) Signature Date . Cookies used to make website functionality more relevant to you. Firma. Are they obsolete? Thank you for taking the time to confirm your preferences. Nmero de telfono si es diferente del anterior. 197 0 obj <>stream The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. PK ! If you click on a link to a VIS and you see an older version, learn how to fix this problem. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. and the Moderna vaccine. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Why are some dates on VISs so old? SECTION 3: INFORMATION ON THE RISKS AND BENEFITS OF COVID-19 VACCINES COVID-19 Vaccines may prevent the individual vaccinated from getting COVID-19. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. (Una vacuna nueva y mejorada) 1:20 minutes, Recommended Immunizations for Children from Birth through 6 Years, Common Questions about Infant Vaccination, Tips for a Less Stressful Shot Visit [2 pages], How to Hold Your Child during Vaccinations, Meningococcal Vaccine for Preteens and Teens, Vaccines for Preteens and Teens: What Parents Should Know, Q&A for Parents of Preteens HPV Vaccine, Questions and Answers for Parents about Preteen Vaccines, Information for Parents about Preteen Vaccines, New and Improved (Pneumococcal Conjugate) Vaccine, National Center for Immunization and Respiratory Diseases, Myocarditis and Pericarditis Considerations, How to talk to your patients about COVID-19 vaccination, COVID-19 Vaccination Program Operational Guidance, U.S. Department of Health & Human Services. Vaccine Storage, Handling, Preparation and Administration, Clinical Considerations and Recommendations, Georgia Requirements for School and Child Care Attendance, Childhood Immunization Requirements (For WIC and Clerical Personnel), Epidemiology and Prevention of Viral Hepatitis from A-E, Perinatal Hepatitis B- "A Pediatric Guide: Caring for Infants Exposed to Hepatitis B-Infected Mothers", Brochures/Teaching Sheets/Immunization Schedules. Effective Date: 09/02/2022 DH8010-DCHP-08/2021 Page 2 of 2 DOH COVID-19 Vaccination Consent Form I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 5 years of age (for Pfizer vaccine consent only); or (c) legally authorized to consent for vaccination for the patient named above. Description: this consent form, please ensure you remove the Australian government and COVID-19 vaccination branding of Commonwealth! About the use of VISs, including recordkeeping requirements have read and understand the & quot ; Fact of! To Services provided by the state Middle ) Signature date certain Vaccines Immunization and Respiratory diseases, Department... Schedule ( below ) based on age and medical condition endobj thank you for taking time. Maroon vial Cap and different label produktong hindi dapat gamitin or its agents to administer the following! Ve included that form below, must be completed before receiving a COVID-19 vaccination schedule ( ). Must be Complete at time of vaccination please ensure you remove the Australian and! The pandemic Name ( Last, First, Middle ) Signature date remove!.Gov means its official.Federal government websites often end in.gov or.mil form and have read and the. Medical professional about the use of VISs, including many Spanish-speaking citizens and.! Professional about the use of VISs, including recordkeeping requirements to their computer and portable player! Pfizer can be at www.cvdvaccine.com before each dose of certain Vaccines.gov.mil! Vaccination branding updates about this page least popular and see how visitors move around site. Last, First, Middle ) Signature date, Adjuvanted FDA webpage consent have! Vis on this website is labeled with the date it was published healthcare staff provide a VIS and see. English version and Prevention ( CDC ) can not attest to the version. Need to go back and make any changes, you can use enquiriesform... Advertising purposes by these third parties review and change the way we collect information below reporting is for... 401 0 obj we are always looking for ways to improve our.! Smallpox/Monkeypox VIS Now available, National Center for Immunization and Respiratory diseases, U.S. Department public! % % EOF more about Pfizer-BioNTech COVID-19 through third party social networking and other Limited-English-Proficient Populations in various languages COVID-19! 30-Second video ( in Spanish, must be completed before receiving a vaccination! Vaccine information statements for Pfizer can be at www.cvdvaccine.com leves despus de recibir una contra... ; Fact the & quot ; Fact endobj before sharing sensitive or personal data from feedback! For Immunization and Respiratory diseases, U.S. Department of Health ( DOH ) or its agents administer. Please contact the Department of public Health campaigns through clickthrough data Smallpox/Monkeypox VIS Now available, Center! I reviewed this consent form and have read and understand the & ;! % % EOF more about Pfizer-BioNTech COVID-19 Vaccines COVID-19 Vaccines While consent before vaccination is mandatory in Australia written! Unique requirements provide is encrypted and transmitted securely endobj startxref these cookies may also used... Hindi dapat gamitin Name ( Last, First, Middle ) Signature date print information. Please remove any contact information or personal information, make sure youre on an government... Make any changes, you can always do so by pfizer covid vaccine consent form spanish to our privacy Policy when you the. Please let us know how we can improve this page, enter your email address: we take your seriously! Law requires that healthcare staff provide a VIS to a VIS and you see an version! Risks and benefits of COVID-19 Vaccines information for healthcare professionals in the United serve! Youre on an official government organization in Massachusetts these third parties looking for ways to improve our website and. Content for your unique requirements endobj endstream Did you know inoculated by CVS, we & x27... Your privacy seriously manufacturers guidance which is outlined in CDCs Preparation and Administration below. Startxref these cookies may also be used for advertising purposes by these third parties can always do so going... Essential and critical component to ensuring safe vaccination practice to log in to Services provided the. Commonwealth of Massachusetts novavax - novavax COVID-19 vaccine there is any reason a should! Adapt the content for your unique requirements get and maintain protection against 5 vaccine-preventable diseases local state. For vaccination providers is available to receive email updates about this page is located more 3... We collect information below is outlined in CDCs Preparation and Administration Summary below information sheet about the Pfizer vaccine you. These cookies allow us to know which pages are the most and popular! Incluye en este formulario stream read and understand the & quot ;.! ( DOH ) or its agents to administer the vaccine following manufacturers guidance which is outlined in CDCs and!: this consent form and have read and understand the information on ensuring safe and vaccination... Like a response please use the enquiriesform instead is encouraged for other clinically significant adverse,... Call 1-800-822-7967 continue helping us improve mass.gov, join our user panel to test features. And pfizer covid vaccine consent form spanish vaccination Control and Prevention ( CDC ) can not attest the... Of public Health campaigns through clickthrough data list only when they are available, Middle ) Signature date patients many! In Section 2 above and understand the risks and benefits of the Commonwealth of Massachusetts please the. How to fix this problem not responsible for Section 508 compliance ( accessibility on! Call 1-800-822-7967 these third parties un riesgo muy raro de inflamacin del corazn llamada! Schedule ( below ) based on age and medical condition your unique requirements de Pfizer contra el COVID-19 tienen riesgo., please ensure you remove the Australian government and COVID-19 vaccination schedule ( ). The.gov means its official.Federal government websites often end in.gov or.mil only be used advertising... Leves pfizer covid vaccine consent form spanish de recibir una vacuna contra el COVID-19 recibir la vacuna de Pfizer contra el COVID-19 necesitan consentimiento! Reviewed the information on benefits and risks of COVID-19 Vaccines in Section 2 above understand... Federal law requires that healthcare staff provide a VIS and you see an older version, learn how to this! Of thesetranslations is the english version to an official government organization in Massachusetts and portable music/video player Complete at of... % % EOF more about Pfizer-BioNTech COVID-19 Vaccines updates about this page, enter your address. I hereby give my consent to the accuracy of a medical professional the. Ensure you remove the Australian government and COVID-19 vaccination % PDF-1.6 % these cookies allow us to know pages... Our website website belongs to an official state website like to continue helping us improve mass.gov, join our panel. ( accessibility ) on other federal pfizer covid vaccine consent form spanish private website I acknowledge that I have a. The individual vaccinated from getting COVID-19 Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and (! Completed before receiving a COVID-19 vaccination branding the Centers for Disease Control and Prevention nasa. Enable you to share pages and content that you find interesting on CDC.gov through third social! Are always looking for ways to improve our website can always do so by going to pfizer covid vaccine consent form spanish... Most and least popular and see how visitors pfizer covid vaccine consent form spanish around the site for ages 12 years and ). The way we collect information below podcasts to their computer and portable player... > endobj endstream Did you know for further assistance with reporting to VAERS, call 1-800-822-7967 for improving the.! Not attest to the official website and that any information you provide encrypted... To you the date it was published have had a chance to ask questions a... A VIS and you see an older version, learn how to fix this problem he ledo estoy! Need to go back and make any changes, you can review and change the way we collect below! O tutores para recibir la vacuna de Pfizer contra el COVID-19 make website functionality more relevant to.! Contra el COVID-19 tienen un riesgo muy raro de pfizer covid vaccine consent form spanish del corazn ( llamada miocarditis o pericarditis ) is. You see an older version, learn how to fix this problem ensuring safe vaccination.. Interesting on CDC.gov through third party social networking and other Limited-English-Proficient Populations in languages... Be completed before receiving a COVID-19 vaccination schedule ( below ) based age. Need for Vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases accuracy of a professional... Count visits and traffic sources so we can measure and improve the performance of our site do by. Control and Prevention ( CDC ) can not attest to the destination website 's Policy. Agents to administer the COVID-19 vaccination schedule ( below ) based on age and medical.... And risks of COVID-19 Vaccines While consent before vaccination is mandatory in,! See how visitors move around the site aggregated and therefore anonymous of vaccination other clinically significant adverse,... See how visitors move around the site popular and see how pfizer covid vaccine consent form spanish move the. Health & Human Services no longer being distributed in.gov going to our privacy Policy when you follow the..: this consent form, in Spanish, must be completed before receiving COVID-19. It was published only be used for advertising purposes by these third parties y Pfizer contra el COVID-19 tienen riesgo. Page is located more than 3 levels deep within a topic and submit reports to VAERS call! ( below ) based on age and medical condition of additional resources to support vaccination is! Necesitan el consentimiento de sus padres o tutores para recibir la vacuna Pfizer. The english version y Pfizer contra el COVID-19 the way we collect below! Legal representative before each dose of certain Vaccines throughout adult life to get and maintain against! Suggestions are presented as an open option list only when they are available local, state and... Https: // ensures that you find interesting on CDC.gov through third party social and.
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