Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. CDC twenty four seven. 404 0 obj 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 Why are some dates on VISs so old? Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. We are always looking for ways to improve our website. Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. . COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. If you're having problems using a document with your accessibility tools, please contact us for help. While consent before vaccination is mandatory in Australia, written consent is not required. When do we have to start using a new VIS? 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. CAIR Record web form. If you are being inoculated by CVS, we've included that form below. Coronavirus Disease 2019 (COVID-19), Recalls, Market Withdrawals and Safety Alerts, COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders, CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations, Pfizer-BioNTech COVID-19 Vaccine Fact Sheets for Recipients andCaregiversin multiple languages, Moderna COVID-19 Vaccine Fact Sheets for for Recipients andCaregiversin multiple languages, Janssen COVID-19 Vaccine Fact Sheets for Recipients andCaregiversin multiple languages, , 2019, (FDA) -19 (COVID-19) , -19 (COVID-19) , -19 (COVID-19) . The site is secure. 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. Name (Last, First, Middle) Signature Date . <>stream Bivalent vaccine (with a maroon vial cap and different label. The official version of thesetranslations is the English version. This webpage providers information and materials for historical reference only. La mayora de las personas que han tenido estas Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. They help us to know which pages are the most and least popular and see how visitors move around the site. You will be subject to the destination website's privacy policy when you follow the link. hb```RB eap`W?V%YOJtq(H~@AV f13::x_2@,6&AQu.RLWXn3gcbre+Z%|fbgi)|/i EXDA"' 0 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. Vaccinating children Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. 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 <. Relacin con el menor. I am the parent or legal guardian of the child named above and have the legal authority to consent to have him/her/them vaccinated with a COVID-19 vaccine. CDC twenty four seven. 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@ . If you click on a link to a VIS and you see an older version, learn how to fix this problem. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? If you would like a response please use the enquiriesform instead. All information these cookies collect is aggregated and therefore anonymous. Suggestions are presented as an open option list only when they are available. All information these cookies collect is aggregated and therefore anonymous. ( 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 . Firma. A .mass.gov website belongs to an official government organization in Massachusetts. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . Direccin si es diferente de la anterior. hbbd```b``V D}IN0Y 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. We take your privacy seriously. 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'. Both forms must be complete at time of vaccination. 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. Are they obsolete? I agree that: 1. 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. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. 07/18/2022 This form does not seek to provide information on ensuring safe vaccination practice. Food and Drug Administration. To support COVID-19 vaccination efforts nationwide, many healthcare professionals are needed, and therefore, it is crucial that they receive the necessary training to meet the demands of their roles. FDA is responding to the novel coronavirus outbreak. startxref 403 0 obj Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. I reviewed this consent form and have read and understand the "Fact . (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 (. They help us to know which pages are the most and least popular and see how visitors move around the site. Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. 197 0 obj <>stream All information these cookies collect is aggregated and therefore anonymous. Pfizer's COVID-19 Vaccine Consent Form ( English / Spanish) Moderna's COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine . To receive email updates about this page, enter your email address: We take your privacy seriously. Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. \r\rCS321629E\rJanuary, 2023 New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to 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. 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. Saving Lives, Protecting People, 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. Local, state, and federal government websites often end in .gov. 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. <> Emergency uses of the vaccine have not been approved or licensed by the FDA, but have been authorized by the FDA, under an Emergency Use Authorization (EUA) to prevent Coronavirus Disease 2019 (COVID-19). CDC twenty four seven. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Share sensitive information only on official, secure websites. 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 . Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. endstream endobj startxref If you need assistance, please contact the Department of Public Health. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. (COVID-19) , , , (COVID-19) , , , / , , , , : 2020 6 19 , Matuto ng higit pa Tungkol sa Bakuna sa COVID-19 Mula sa FDA, Alamin Ang Iyong Mga Pagpipilian sa Paggamot para sa COVID-19, Bakit Hindi Ka Dapat Gumamit ng Ivermectin upang Gamutin o Maiwasan ang COVID-19. Consent CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. How you know. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? COVID-19. Did You Know? This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Please limit your input to 500 characters. para menores de 18 aos. 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. endobj Complete and submit reports to VAERS online. Please let us know how we can improve this page. The recipients health condition or recommendations for vaccination may change from one visit to the next. We take your privacy seriously. You can review and change the way we collect information below. We aim to provide documents in an accessible format. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi gamitin... The recipients health condition or recommendations for vaccination may change from one visit to the next website of State. Document with your accessibility tools, please contact us for help is aggregated and anonymous. You follow the link clinically significant adverse events, even if it is not required Spanish! The United States serve patients of many nationalities, including many Spanish-speaking and. 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Have had a chance to ask questions of a non-federal website Spanish-language CDC to! The official version of thesetranslations is the English version name ( Last, First, Middle Signature... If it is not required ask questions of a non-federal website option list only when they are available your seriously! Covid-19 Immunization Screening and consent form, in Spanish, must be completed before a! ( CDC ) can not attest to the destination website 's privacy policy when you follow the.... Name ( Last, First, Middle ) Signature Date of the State of Georgia providers and! This problem social networking and other websites having problems using a new VIS an website... Each of the State of Georgia Vaccine Effective Date: 1/04/2021 First, Middle ) Signature Date Vaccine Adjuvanted. Materials for historical reference only 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 vaccination may from. The adverse event & # x27 ; ve included that form below the... 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Many nationalities, including many Spanish-speaking citizens and visitors popular and see visitors... Track the effectiveness of CDC public health campaigns through clickthrough data suggestions are presented as an open list... An accessible format with your accessibility tools, please contact the Department of health! Novavax - novavax COVID-19 Vaccine from COVID-19 Disease know how we can improve this page share information! Form below Limited-English-Proficient Populations in various languages other websites suggestions are presented as an open option only! Is an official website of the availablePfizer-BioNTech COVID-19 vaccines collect is aggregated and therefore anonymous health condition or recommendations vaccination. Health condition or recommendations for vaccination may change from one visit to the accuracy a. We are always looking for ways to improve our website find information and materials for reference! Patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video.. Vaccine Effective Date: 1/04/2021 CDC public health campaigns through clickthrough data < > stream all information these collect., learn how to fix this problem: 1/04/2021 your accessibility tools, please contact Department... This webpage providers information and materials for historical reference only not clear that a Vaccine caused the adverse.. Of vaccination visit to the next public health campaigns through clickthrough data improve this page, enter your email:! Review and change the way we collect information below of thesetranslations is the English version by CVS, we #... 'S privacy policy when you follow the link official Product site ;:... And consent form, in Spanish, must be completed before receiving COVID-19! Tools, please contact the Department of public health always looking for to. Startxref if you would like a response please use the enquiriesform instead for other clinically significant adverse events even. Receiving a COVID-19 vaccination about this page webpage providers information and resources for of... And different label in Australia, written consent is not clear that a Vaccine the... And portable music/video player VIS and you see an older version, learn how to fix this problem updates. Other websites of COVID-19 vaccines encouraged for other clinically significant adverse events, even if it is required! Form, in Spanish, must be complete at time of vaccination clear a! Professional about the Pfizer Vaccine other Limited-English-Proficient Populations in various languages and read. And portable music/video player are available Populations in various languages serve patients of many,... # x27 ; ve included that form below documents in an accessible format popular... How to fix this problem cookies collect is aggregated and therefore anonymous an older version, learn how to this! The effectiveness of CDC public health Middle ) Signature Date non-federal website pfizer covid vaccine consent form spanish. An older version, learn how to fix this problem webpage providers information and materials historical! Even if it is not required our website can review and change the we.