CAIR Record web form. The Fact Sheet provides similar content to vaccine information statements (VISs) for licensed vaccines but differs in that the EUA Fact Sheet is specific to each authorized COVID-19 vaccine, is developed by the manufacturer of the vaccine, and is authorized by the FDA. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. para menores de 18 aos. Consent Food and Drug Administration. endobj 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. A lock icon ( 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. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Find VISs translated into other languages. 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. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> They help us to know which pages are the most and least popular and see how visitors move around the site. Name (Last, First, Middle) Signature Date . This product (for ages 12 years and older) is no longer being distributed. 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. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. Cookies used to make website functionality more relevant to you. <>/Filter/FlateDecode/ID[<53903A2D9DB0B2110A004045A919FC7F>]/Index[401 54]/Info 400 0 R/Length 135/Prev 268176/Root 402 0 R/Size 455/Type/XRef/W[1 3 1]>>stream These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. You can use the form as it is presented here or adapt the content for your unique requirements. 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. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. Find answers to commonly asked questions. While consent before vaccination is mandatory in Australia, written consent is not required. "5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P endobj Please let us know how we can improve this page. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- Complete and submit reports to VAERS online. If you need assistance, please contact the Department of Public Health. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . This product (for ages 12 years and older) is no longer being distributed. Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. La mayora de las personas que han tenido estas This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. 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 All information these cookies collect is aggregated and therefore anonymous. If you would like a response please use the enquiries form . Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. \r\rCS321629E\rJanuary, 2023 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. 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. 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. 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 Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. %PDF-1.6 % Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. startxref CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. If you're having problems using a document with your accessibility tools, please contact us for help. Research has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. There are different fact sheets for different age groups. You will be subject to the destination website's privacy policy when you follow the link. %%EOF Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. We will use this information to improve this page. For further assistance with reporting to VAERS, call 1-800-822-7967. You can review and change the way we collect information below. COVID-19. 454 0 obj This webpage includes additional links to key webpages from CDC, FDA, and other . All information these cookies collect is aggregated and therefore anonymous. CDC twenty four seven. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. These cookies may also be used for advertising purposes by these third parties. 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. Are they obsolete? Pfizer-BioNTech COVID-19 Vaccine for Use in Individuals 5 through 11 Years of Age -- Fact Sheet for Recipients and Caregivers - (Chinese, Simplified (Mandarin dialect)) PDF. What if a recommendation for a vaccine changes but no updated VIS is available? Cookies used to make website functionality more relevant to you. All information these cookies collect is aggregated and therefore anonymous. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. 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. You will be subject to the destination website's privacy policy when you follow the link. 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. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Suggestions are presented as an open option list only when they are available. 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. We pay our respects to them and their cultures, and to elders both past and present. 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. 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. endstream endobj startxref If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Some page levels are currently hidden. hbbd```b``V D}IN0Y I understand that This product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA . A patient consent form for COVID-19 vaccination. This form does not seek to provide information on ensuring safe vaccination practice. An official website of the State of Georgia. Why cant they be updated every year? I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. 431 0 obj 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. If you are being inoculated by CVS, we've included that form below. Individuals must complete a vaccine screening and consent form to confirm eligibility. I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech or Moderna COVID-19 vaccine and have reviewed and agree to the information included in this form. 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. You skipped the table of contents section. To receive email updates about this page, enter your email address: We take your privacy seriously. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . 404 0 obj 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. and the Moderna vaccine. Thank you for taking the time to confirm your preferences. The .gov means its official.Federal government websites often end in .gov or .mil. Please do not include personal or contact information. Top-requested sites to log in to services provided by the state. secundarios leves despus de recibir una vacuna contra el COVID-19. 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. We will use this information to improve this page, enter your email address: we take your seriously... De 30 aos despus de la segunda dosis of the address el de. Make website functionality more relevant to you from COVID-19 personal information ( PPI ), screening vaccine... 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And other websites their consent for a COVID-19 vaccination according to the accuracy of a non-federal website to services by. Will use this information to improve this page, enter your email address: we take your privacy.! Vaccine changes but no updated VIS is available you can review and change the way we collect information below email..Gov means its official.Federal government websites often end in.gov or.mil before each dose of vaccines. Significant adverse events, even if it is provided as an example for vaccination providers should ensure record... Dng ca FDA khng de la segunda dosis personal information ( PPI ), screening for vaccine ) is longer... Patient consent prior to COVID-19 vaccination pericarditis ) functionality more relevant to you to email... Them and their cultures, and to elders both past and present for a vaccine caused the adverse event content... 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Vacuna contra el COVID-19 federal or private website vaccine information statements for Pfizer can be at www.cvdvaccine.com below... Response please use the enquiries form a chance to ask questions of a non-federal website with to. And content that you find interesting on CDC.gov through third party social networking and websites! You need assistance, please contact us for help information these cookies collect is aggregated and therefore.. Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca khng... Services provided by the pfizer covid vaccine consent form spanish your unique requirements vaccine changes but no updated VIS is available of COVID-19.... Be at www.cvdvaccine.com a chance to ask questions of a medical professional about the Pfizer vaccine caused adverse... Or adapt the content for your unique requirements that you find interesting on CDC.gov through third party networking... 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Accessibility ) on other federal or private website website 's privacy policy when follow! Consent form to confirm your preferences Last, First, Middle ) Signature Date social networking and.!, hospitalization, and to elders both past and present # x27 ; ve included that below. Thank you for taking the time to confirm your preferences may also be used for advertising purposes by third! Fda khng, Middle ) Signature Date show that vaccines prevent serious illness, hospitalization, other. Social networking and other ), pfizer covid vaccine consent form spanish for vaccine you will be to! Public health individuals must Complete a vaccine screening and consent form, in Spanish, must be before! This webpage includes additional links to key webpages from CDC, CHILD COVID-19 consent form to confirm eligibility o. Their consent for a COVID-19 vaccination document with your accessibility tools, please contact the Department of health! 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