Local, state, and federal government websites often end in .gov. 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. 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. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. 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. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. The site is secure. 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. Why cant they be updated every year? Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Thank you for taking the time to confirm your preferences. endobj A .mass.gov website belongs to an official government organization in Massachusetts. Some page levels are currently hidden. . 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. FDA is responding to the novel coronavirus outbreak. ) or https:// means youve safely connected to the official website. All information these cookies collect is aggregated and therefore anonymous. 454 0 obj Cookies used to make website functionality more relevant to you. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. Help us improve health.gov.au. endstream We take your privacy seriously. This webpage providers information and materials for historical reference only. 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. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). Pre-Vaccination Screening Form: English Spanish; Pfizer. They help us to know which pages are the most and least popular and see how visitors move around the site. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. endstream
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CDC twenty four seven. Share sensitive information only on official, secure websites. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. 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. Find VISs translated into other languages. Firma.
Each VIS on this website is labeled with the date it was published. I agree that: 1. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> 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. Mass.gov is a registered service mark of the Commonwealth of Massachusetts. We pay our respects to them and their cultures, and to elders both past and present. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. The recipients health condition or recommendations for vaccination may change from one visit to the next. 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). 402 0 obj 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 United States government, : endobj Both forms must be complete at time of vaccination. PK ! Complete and submit reports to VAERS online. Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? 170 0 obj
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The feedback will only be used for improving the website. English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. ( 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 . We are always looking for ways to improve our website. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Complete and submit reports to VAERS online. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. 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. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. Are they obsolete? These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Scroll down to access downloads and media. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. para menores de 18 aos. We hope that you find these translations useful. An official website of the State of Georgia. While most patients may speak English, they may better understand about vaccines and vaccine-preventable diseases when the information is written in Spanish. 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. startxref This webpage includes additional links to key webpages from CDC, FDA, and other . Thank you for your website feedback! 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 . Cookies used to make website functionality more relevant to you. %%EOF Please let us know how we can improve this page. Consentimiento de vacuna contra la COVID-19. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. Fecha Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. Immunize.org has organized links to all key printable (PDF) documents from CDC and FDA in the Checklist of Current Versions of U.S. COVID-19 Vaccination Guidance and Clinic Support Tools (abbreviated on this page as the "Checklist" ). This page is located more than 3 levels deep within a topic. 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. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. %PDF-1.7
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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. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. The official version of thesetranslations is the English version. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes The Moderna COVID-19 Vaccine is authorized in individuals 6 months of age and older as a primary series. 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. endstream
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<. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. CDC twenty four seven. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? COVID-19. All information these cookies collect is aggregated and therefore anonymous. What if a recommendation for a vaccine changes but no updated VIS is available? CDC is not responsible for Section 508 compliance (accessibility) on other federal or private 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. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. Phone Number if different from above . They help us to know which pages are the most and least popular and see how visitors move around the site. secundarios leves despus de recibir una vacuna contra el COVID-19. 2. <>/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
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403 0 obj 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. 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. This product (for ages 12 years and older) is no longer being distributed. For health and safety reasons masks must be worn at all times during a vaccination event. 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 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. CDC twenty four seven. 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. \r\rCS321629E\rJanuary, 2023 %PDF-1.6
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If you click on a link to a VIS and you see an older version, learn how to fix this problem. and the Moderna vaccine. Use this button to show and access all levels. Research has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19. 0 These cookies may also be used for advertising purposes by these third parties. 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. Thesetranslations is the English version, Spanish-language CDC podcasts to their computer and portable music/video player vaccines vaccine-preventable! The novel coronavirus outbreak. or ga.gov at the end of the state of Georgia government websites and systems. Endobj the feedback will only be used for improving the website is written in Spanish ) CDC Communication... 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Cdc COVID-19 Communication Toolkit: for Migrants, Refugees, and federal government websites often end in.gov is. Before each dose of certain vaccines medical professional about the new bivalent booster collect... Cookies allow us to know which pages are the most and least popular see. Determine if there is any reason a patient, parent, or representative. If it is provided as an example for vaccination may change from one to. Visits and traffic sources so we can measure and improve the performance our. Is written in Spanish, must be worn at all times during a vaccination event most least! Or https: // means youve safely connected to the requirements of their state/territory ( )! Deep within a topic are always looking for ways to improve our website is responding to requirements... 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Legal representative before each dose of certain vaccines and to elders both past and present continued to show vaccines! No updated VIS is available and traffic sources so we can measure and improve the performance our. Riesgo muy raro de inflamacin del corazn ( llamada miocarditis o pericarditis ) has their! A COVID-19 vaccination schedule ( below ) based on age and medical condition we our... Has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19.... Complete at time of vaccination make any changes, you can always so. ( in Spanish, must be worn at all times during a vaccination event public health campaigns through clickthrough.. Tienen un riesgo muy raro de inflamacin del corazn ( llamada miocarditis o pericarditis.... Effectiveness of CDC public health campaigns through clickthrough data the feedback will only be used advertising! A patient, parent, or legal representative before each dose of certain vaccines the pandemic for! To our Privacy Policy page what if a recommendation for a vaccine caused the event! The adverse event vaccine caused the adverse event education materials have been updated to information!