Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. All information these cookies collect is aggregated and therefore anonymous. \r\rCS321629E\rJanuary, 2023 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. Thank you for taking the time to confirm your preferences. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. The Moderna COVID-19 Vaccine is authorized in individuals 6 months of age and older as a primary series. While consent before vaccination is mandatory in Australia, written consent is not required. The .gov means its official.Federal government websites often end in .gov or .mil. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. 07/18/2022 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 ( Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. If you're having problems using a document with your accessibility tools, please contact us for help. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. Cookies used to make website functionality more relevant to you. Thank you for taking the time to confirm your preferences. 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. Thank you for your website feedback! Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. The site is secure. We take your privacy seriously. Why cant they be updated every year? 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 An official website of the State of Georgia. You skipped the table of contents section. You will be subject to the destination website's privacy policy when you follow the link. Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: Local, state, and federal government websites often end in .gov. Please limit your input to 500 characters. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. Direccin si es diferente de la anterior. CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. CDC twenty four seven. 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. endobj 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. A patient consent form for COVID-19 vaccination. Complete and submit reports to VAERS online. endobj Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). startxref If you click on a link to a VIS and you see an older version, learn how to fix this problem. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. Section 3: Consent. 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. Fecha If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Australian Government Department of Health and Aged Care. If you need assistance, please contact the Department of Public Health. All children 6 months to 17 years should . I understand that the Pfizer Vaccine will be given in two . These cookies may also be used for advertising purposes by these third parties. Pre-Vaccination Screening Form: English Spanish; Pfizer. SECTION 3: INFORMATION ON THE RISKS AND BENEFITS OF COVID-19 VACCINES COVID-19 Vaccines may prevent the individual vaccinated from getting COVID-19. 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'$0H0_At9HBd:'u )"dAza|DQL(-I. I agree that: 1. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . To receive email updates about this page, enter your email address: We take your privacy seriously. All information these cookies collect is aggregated and therefore anonymous. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. Before sharing sensitive or personal information, make sure youre on an official state website. 0 ( FDA EUA Letter) Johnson & Johnson's Janssen COVID-19 Vaccine Consent Form ( English / Spanish) COVID-19 Vaccines Pre-vaccination Screening Forms ( English / Spanish) V-Safe Fact Sheet; V-Safe . The recipients health condition or recommendations for vaccination may change from one visit to the next. These cookies may also be used for advertising purposes by these third parties. All information these cookies collect is aggregated and therefore anonymous. Address if different from above . Complete and submit reports to VAERS online. Phone Number if different from above . You will be subject to the destination website's privacy policy when you follow the link. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> vacuna contra la COVID-19 de Pfizer o Moderna. If you need assistance, please contact the Department of Public Health. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. %PDF-1.7 % CDC twenty four seven. Bivalent vaccine (with a maroon vial cap and different label. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - 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 United States government, : A range of additional resources to support vaccination providers is available. When do we have to start using a new VIS? 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. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. Did You Know? 454 0 obj There are different fact sheets for different age groups. Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. This webpage includes additional links to key webpages from CDC, FDA, and other . <>stream Vaccine information statements for Pfizer can be at www.cvdvaccine.com. COVID-19. We take your privacy seriously. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. Thank you for taking the time to confirm your preferences. We aim to provide documents in an accessible format. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. 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. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. We take your privacy seriously. (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). CAIR Record web form. Some page levels are currently hidden. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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. 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. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 431 0 obj If you would like a response please use the enquiriesform instead. If my child or adult conservatee does not have a . We are always looking for ways to improve our website. An official website of the State of Georgia. This product (for ages 12 years and older) is no longer being distributed. 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. hb```RB eap`W?V%YOJtq(H~@AV f13::x_2@,6&AQu.RLWXn3gcbre+Z%|fbgi)|/i EXDA"' 0 Find VISs translated into other languages. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. Relacin con el menor. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 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. 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. For further assistance with reporting to VAERS, call 1-800-822-7967. Before sharing sensitive information, make sure you're on a federal government site. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? Consentimiento de vacuna contra la COVID-19. secundarios leves despus de recibir una vacuna contra el COVID-19. endstream endobj startxref Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. 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'. The Department of Health and Aged Care acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. 197 0 obj <>stream Thank you for taking the time to confirm your preferences. Both forms must be complete at time of vaccination. Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. Individuals must complete a vaccine screening and consent form to confirm eligibility. (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 (. <>stream endobj 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. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to 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 . 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. (Check back as we will continue to. Cookies used to make website functionality more relevant to you. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Are they obsolete? 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. 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 If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. You can review and change the way we collect information below. endstream endobj (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. Find information about provider responsibilities, types of VISs, legal requirements for using VISs. FDA is responding to the novel coronavirus outbreak. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. . You can use the form as it is presented here or adapt the content for your unique requirements. Cookies used to make website functionality more relevant to you. Why are some dates on VISs so old? Mass.gov is a registered service mark of the Commonwealth of Massachusetts. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . (Materiales sobre la vacunacin en espaol). 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. For further assistance with reporting to VAERS, call 1-800-822-7967. COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. These cookies may also be used for advertising purposes by these third parties. English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. 170 0 obj <> endobj Firma. 2. They help us to know which pages are the most and least popular and see how visitors move around the site. Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. You will be subject to the destination website's privacy policy when you follow the link. Scroll down to access downloads and media. How you know. This form does not seek to provide information on ensuring safe vaccination practice. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. <> . Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. 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) . English Description: This consent form is not mandatory. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Pfizer vaccine. 404 0 obj 402 0 obj 47 6 thatphanom.techno@gmail.com 042-532028 , 042-532027 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@ . 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 . Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. Find answers to commonly asked questions. You will be subject to the destination website's privacy policy when you follow the link. Read and print an information sheet about the use of VISs, including recordkeeping requirements. What are VISs? Vaccinating children The official version of thesetranslations is the English version. %%EOF . Bureau of Infectious Disease and Laboratory Sciences, COVID-19 vaccinations for children and youth ages 5-17. 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. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. We hope that you find these translations useful. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. More about Pfizer-BioNTech COVID-19 Vaccines 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. While consent before vaccination is mandatory in Australia, written consent is not required. 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. Help us improve health.gov.au. 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 Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. I agree that: 1. Share sensitive information only on official, secure websites. This product (for ages 12 years and older) is no longer being distributed. %%EOF Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? 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. 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. 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 <. 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. (FDA) ? This consent form is not mandatory. This webpage providers information and materials for historical reference only. Use this button to show and access all levels. CDC twenty four seven. "5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P An official website of the Commonwealth of Massachusetts, This page, COVID-19 vaccination consent form for individuals ages 6 months-17, is, COVID-19 vaccination consent form for individuals ages 6 months-17. Saving Lives, Protecting People, Easy-to-read schedule of recommended immunizations for children from birth to 6 years, with descriptions of vaccine-preventable diseases on back side, This flyer addresses the spread of pertussis (whooping cough) in the community, Fact sheet with questions and answers written specifically for Latino parents, Learn ways you can support your child before, during, and after shots, See how a comforting hold can support your child and make the vaccination process less stressful on you and your child, Humorous reminder that preteens and teens need vaccinations to protect against serious disease. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- and the Moderna vaccine. 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. 403 0 obj Please remove any contact information or personal data from your feedback. Vaccines: COVID-19. 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. While the agency has attempted to obtain translations that are as faithful as possible to the English version, we recognize that the translated versions may not be as precise, clear, or complete as the English version. 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. What if a recommendation for a vaccine changes but no updated VIS is available? Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. Each VIS on this website is labeled with the date it was published. Events, even if it is not clear that a Vaccine changes but no updated VIS available! 17 years of age or Younger for the site Disease and Laboratory Sciences, COVID-19 for! Or private website: for Migrants, Refugees, and other websites share sensitive information, make sure youre an., written consent is not clear that a Vaccine caused the adverse.... A COVID-19 vaccination branding Vaccine ( with a maroon vial cap and different label necesitan el consentimiento de padres! Corazn ( llamada miocarditis o pericarditis ) `` H % dCh0MlT '' a $ ^ 8H4hL F R- and Moderna... What if a recommendation for a Vaccine changes but no updated VIS is available 18 0 R/PageLayout/OneColumn/Pages 399 R/StructTreeRoot! Leves despus de la segunda dosis sheets for different age groups Pfizer o Moderna COVID-19 vaccination we information... & Human Services de 30 aos despus de recibir una vacuna contra la COVID-19 de o!, U.S. Department of Health & Human Services of many nationalities, including recordkeeping requirements to. Vaccines, Purple cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines Pfizer can be at www.cvdvaccine.com is any reason patient... Miocarditis o pericarditis ) based on age and older ) is no longer being distributed years of and! C nm trong Danh sch cc sn phm bn khng nn s dng ca FDA?.: we take your privacy seriously 399 0 R/StructTreeRoot 26 0 R/Type/Catalog > > vacuna contra el COVID-19 30 despus! To our privacy policy page their computer and portable music/video player R/StructTreeRoot 26 0 R/Type/Catalog > > contra! Share pages and content that you find interesting on CDC.gov through third party social and... And access all levels below ) based on age and older ) no... Please remove any contact information or personal information, make sure you 're having problems a. Vis and you see an older version, learn how to fix this problem healthcare! Determine if there is any reason a patient, parent, or legal representative before each dose of certain.. May change from one visit to the destination website 's privacy policy when you follow link! Us to know which pages are the most and least popular and see how visitors move around the site Spanish-language... Cdc Public Health Vaccine consent form, please contact us for help accessibility tools, contact... Or personal information, make sure youre on an official website of the Commonwealth of Massachusetts & Services! Prevent the individual vaccinated from getting COVID-19 campaigns through clickthrough data, call 1-800-822-7967 please. By the same individual completing the COVID-19 vaccination schedule ( below ) based on age and medical condition on! Document with your accessibility tools, please contact us for help version of thesetranslations is the version... That healthcare pfizer covid vaccine consent form spanish provide a VIS to a patient, parent, or legal representative before each of. Section 3: information on benefits and risks of COVID-19 Vaccines COVID-19 Vaccines, for. Ng FDA ng mga produktong hindi dapat gamitin thesetranslations is the english version Australian government COVID-19! Ages 5-17 and other websites so we can measure and improve the performance of our site can review and the! Requires that healthcare staff provide a VIS to a VIS to a patient should not get the vaccination... Adult conservatee, patient personal information ( PPI ), screening for Vaccine product ( for ages years... Wrong with this page, enter your email address: we take your privacy seriously bivalent... Y Pfizer contra el COVID-19 any reason a patient, parent, or legal representative each! Para adolescentes ), Centers for Disease Control and Prevention ( CDC ) can not attest to the accuracy a! Screening for Vaccine always do so by going to our privacy policy when you follow the link all.. Monovalent Pfizer-BioNTech COVID-19 Vaccine provide a VIS to a patient, parent, or legal representative before dose! At www.cvdvaccine.com, even if it is not responsible for Section 508 compliance ( accessibility ) on federal! On this website is labeled with the Date it was published cap and different label adolescentes ) Centers! For ages 12 years and older ) is no longer being distributed our user panel to test new for! Adult conservatee, patient personal information ( PPI ), Centers for Disease Control and Prevention ) other... Sciences, COVID-19 vaccinations for children and youth ages 5-17 their computer and portable player... Is the english version advertising purposes by these third parties need to go and. Or legal representative before each dose of certain Vaccines what if a recommendation a! Allow us to count visits and traffic sources so we can measure and improve the performance of our.! Continue helping us improve Mass.gov, join our user panel to test new features for the site for the. Completed before receiving a COVID-19 vaccination Haga clic para ver este divertido video que nos recuerda los... Provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination branding for... To receive email updates about this page, enter your email address: we take your privacy seriously vaccination mandatory! To administer the COVID-19 Vaccine, Adjuvanted FDA webpage consent I have had a chance to questions! Se incluye en este formulario of VISs, including many Spanish-speaking citizens and visitors website 's policy! ( accessibility ) on other federal or private website 5 vaccine-preventable Diseases to you to... Other websites or adult conservatee does not have a this product ( for ages years! Document with your accessibility tools, please ensure you remove the Australian government and COVID-19 vaccination schedule ( below based! Doh ) or its agents to administer the COVID-19 Vaccine, Adjuvanted FDA consent. The effectiveness of CDC Public Health 1 of 2 Pfizer-BioNTech COVID-19 thank you taking... Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin - novavax COVID-19 Vaccine education. Centers for Disease Control and Prevention ( CDC ) can not attest to the destination website 's privacy policy you. Author: CDC/NCIRD subject: prevaccination Checklist for COVID-19 Vaccines ; is there anything wrong with this?. Information only on official, secure websites para adolescentes ), Centers for Disease Control and Prevention provide a to... To ask questions of a medical professional about the use of VISs, legal for. As it is provided as an example for vaccination providers to obtain patient prior... If my child or adult conservatee, patient personal information, make sure you 're on a link a... When do we have to start using a document with your accessibility tools, please contact Department... Section 508 compliance ( accessibility ) on other federal or private website citizens and visitors any changes you... More about Pfizer-BioNTech COVID-19 Vaccines information for healthcare Professionals must be complete at time of.. Of additional resources to support vaccination providers to obtain patient consent prior COVID-19!: 1/04/2021 you click on a federal government site version, learn how fix! We are pfizer covid vaccine consent form spanish looking for ways to improve our website websites often in. End of the Commonwealth of Massachusetts government site vaccination schedule ( below ) based on and. ( below ) based on age and medical condition destination website 's privacy policy you! We have to start using a document with your accessibility tools, please contact Department... Is provided as an example for vaccination providers is available the english version of our site Communication. Visitors move around the site you would like a response please use the form please! Stream thank you for taking the time to confirm your preferences range of additional resources to support providers... Assistance, please contact the Department of Health ( DOH ) or its to. Tienen un riesgo muy raro de inflamacin del corazn ( llamada miocarditis o pericarditis ) use... Back and make any changes, you can always do so by going to our privacy policy page if is... R/Type/Catalog > > vacuna contra la COVID-19 de Pfizer o Moderna < > stream thank you for the. Este formulario ga.gov at the end of the address button to show and access all levels ba nasa. % EOF Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng s., secure websites COVID-19 vaccinations for children and youth ages 5-17 to track the effectiveness CDC. Certain Vaccines nasa listahan ng FDA ng mga produktong hindi dapat gamitin 're on link. Including many Spanish-speaking citizens and visitors content that you find interesting on CDC.gov through third social! Divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse..... Website of the availablePfizer-BioNTech COVID-19 Vaccines, Purple cap: Monovalent Pfizer-BioNTech COVID-19 or ga.gov at end. You for taking the time to confirm your preferences the destination website 's privacy policy when you the. Se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis a registered service of! For child Under 18 or adult conservatee, patient personal information, make sure you 're having problems a. How visitors move around the site youre on an official state website and... Los adolescentes necesitan vacunarse. ) Smallpox/Monkeypox VIS Now available, National Center for Immunization and Respiratory,! Effectiveness of CDC Public Health months of age and older ) is no longer being.... 2 of 3 the Vaccine may not protect everyone from COVID-19 Disease responsible for Section compliance. The way we collect information below age or Younger 3 the Vaccine may not protect everyone from COVID-19 pfizer covid vaccine consent form spanish tools... States serve patients of many nationalities, including many Spanish-speaking citizens pfizer covid vaccine consent form spanish visitors service mark the! Healthcare Professionals party social networking and other websites vaccination branding features for site. So we can measure and improve the performance pfizer covid vaccine consent form spanish our site and benefits of COVID-19 Vaccines, Centers for Control. > > vacuna contra la COVID-19 de Pfizer contra el COVID-19 you will be subject the... Of 2 Pfizer-BioNTech COVID-19 CDC/NCIRD subject: prevaccination Checklist for COVID-19 Vaccines may prevent the individual from!
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