We are always looking for ways to improve our website. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 2. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. 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. endobj La mayora de las personas que han tenido estas Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. 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. Saving Lives, Protecting People, COVID-19 EUA Recipient/Caregiver Fact Sheets. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to This webpage includes additional links to key webpages from CDC, FDA, and other . 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. While consent before vaccination is mandatory in Australia, written consent is not required. Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. You will be subject to the destination website's privacy policy when you follow the link. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Cookies used to make website functionality more relevant to you. If you would like a response please use the enquiriesform instead. 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. 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. 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 enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. For health and safety reasons masks must be worn at all times during a vaccination event. 402 0 obj Read and print an information sheet about the use of VISs, including recordkeeping requirements. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. 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. An official website of the State of Georgia.
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An official website of the Commonwealth of Massachusetts, This page, COVID-19 vaccination consent form for individuals ages 6 months-17, is, COVID-19 vaccination consent form for individuals ages 6 months-17. 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. 197 0 obj
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Each VIS on this website is labeled with the date it was published. (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. Both forms must be complete at time of vaccination. endstream 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. 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 . hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U -
vacuna contra la COVID-19 de Pfizer o Moderna. endobj What are VISs? Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. . Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . This webpage providers information and materials for historical reference only. You can review and change the way we collect information below. When do we have to start using a new VIS? Please remove any contact information or personal data from your feedback. Complete and submit reports to VAERS online. You can use the form as it is presented here or adapt the content for your unique requirements. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. <>stream
Before sharing sensitive or personal information, make sure youre on an official state website. We pay our respects to them and their cultures, and to elders both past and present. All information these cookies collect is aggregated and therefore anonymous. Some page levels are currently hidden. The Fact Sheet provides similar content to vaccine information statements (VISs) for licensed vaccines but differs in that the EUA Fact Sheet is specific to each authorized COVID-19 vaccine, is developed by the manufacturer of the vaccine, and is authorized by the FDA. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? Thank you for taking the time to confirm your preferences. Please limit your input to 500 characters. 94 [Content_Types].xml ( Qo0_Qn P= {IW/$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. Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: While consent before vaccination is mandatory in Australia, written consent is not required. 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. CDC twenty four seven. hbbd```b``V D}IN0Y Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Cookies used to make website functionality more relevant to you. 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. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. Australian Government Department of Health and Aged Care. Consentimiento de vacuna contra la COVID-19. 404 0 obj Name (Last, First, Middle) Signature Date . If you're having problems using a document with your accessibility tools, please contact us for help. Section 3: Consent. 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. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. (FDA) ? You can review and change the way we collect information below. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. endobj 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. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. Are they obsolete? New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes 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. Thank you for taking the time to confirm your preferences. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R-
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. endobj 47 6 thatphanom.techno@gmail.com 042-532028 , 042-532027 <>stream
SECTION 3: INFORMATION ON THE RISKS AND BENEFITS OF COVID-19 VACCINES COVID-19 Vaccines may prevent the individual vaccinated from getting COVID-19. COVID-19. Please limit your input to 500 characters. 403 0 obj (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. Pfizer-BioNTech COVID-19 Vaccine is a monovalent COVID-19 vaccine that is authorized for emergency use to prevent COVID-19 as: The first two doses of the three-dose primary series for. 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. Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. Why are some dates on VISs so old? Mass.gov is a registered service mark of the Commonwealth of Massachusetts. Download and print these pieces or give your patients the Spanish-specific URLs and promote on-time vaccination across the life span in Spanish as well as in English. CDC twenty four seven. (Materiales sobre la vacunacin en espaol). endstream
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<. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Individuals must complete a vaccine screening and consent form to confirm eligibility. I agree that: 1. 454 0 obj These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Share sensitive information only on official, secure websites. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? %PDF-1.7
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CAIR Record web form. I reviewed this consent form and have read and understand the "Fact . Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. You will be subject to the destination website's privacy policy when you follow the link. They help us to know which pages are the most and least popular and see how visitors move around the site. We take your privacy seriously. For further assistance with reporting to VAERS, call 1-800-822-7967. We will use this information to improve this page. Cookies used to make website functionality more relevant to you. Firma. PK ! Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. 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@ . Vaccinating children V-Safe After Vaccination Health Checker - English PDF. The .gov means its official.Federal government websites often end in .gov or .mil. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. startxref Phone Number if different from above . COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. 431 0 obj endstream You will be subject to the destination website's privacy policy when you follow the link. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> This consent form is not mandatory. They help us to know which pages are the most and least popular and see how visitors move around the site. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. This page is located more than 3 levels deep within a topic. More about Pfizer-BioNTech COVID-19 Vaccines This webpage providers information and materials for historical reference only. Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. These cookies may also be used for advertising purposes by these third parties. I agree that: 1. If you need assistance, please contact the Department of Public Health. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. . (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 (. A lock icon ( (Check back as we will continue to. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. The feedback will only be used for improving the website. These cookies may also be used for advertising purposes by these third parties. Before sharing sensitive information, make sure you're on a federal government site. Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. If my child or adult conservatee does not have a . How you know. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. We take your privacy seriously. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> Popular Downloads - available on the CDC site To receive email updates about this page, enter your email address: We take your privacy seriously. Relacin con el menor. 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.