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(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 (. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. The site is secure. 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. 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 State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. 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. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. La mayora de las personas que han tenido estas hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- Thank you for taking the time to confirm your preferences. 401 0 obj You can review and change the way we collect information below. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. If you would like a response please use the enquiriesform instead. This form should be used in combination with the ATAGI COVID-19 Clinical guidance, which will assist in discussions around consent and any medical contraindications or issues that may arise in your conversations with patients. Suggestions are presented as an open option list only when they are available. Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. The Pfizer- BioNTech COVID-19 Vaccine is approved by the U.S. Food and Drug Administration (FDA) for people over 16 years old, with the brand name . This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. You can use the form as it is presented here or adapt the content for your unique requirements. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). English Description: This consent form is not mandatory. Please limit your input to 500 characters. We take your privacy seriously. \r\rCS321629E\rJanuary, 2023 94 [Content_Types].xml ( Qo0_Qn P= {IW/$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. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. 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 <. Cookies used to make website functionality more relevant to you. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. endobj I reviewed this consent form and have read and understand the "Fact . Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. Food and Drug Administration. Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. Vaccinating children Complete and submit reports to VAERS online. ( 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 . Thank you for your website feedback! Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> The recipients health condition or recommendations for vaccination may change from one visit to the next. 2. Help us improve health.gov.au. <>stream Read and print an information sheet about the use of VISs, including recordkeeping requirements. This page is located more than 3 levels deep within a topic. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 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. 0 187 0 obj <>/Filter/FlateDecode/ID[<3C4CB76F7817EC43BD8A3A51D7CF58C8>]/Index[170 28]/Info 169 0 R/Length 90/Prev 97852/Root 171 0 R/Size 198/Type/XRef/W[1 3 1]>>stream Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. . (Check back as we will continue to. 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. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? How you know. 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. English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. You will be subject to the destination website's privacy policy when you follow the link. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. If you need assistance, please contact the Department of Public Health. More about Pfizer-BioNTech COVID-19 Vaccines While consent before vaccination is mandatory in Australia, written consent is not required. A patient consent form for COVID-19 vaccination. 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. Complete and submit reports to VAERS online. New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes Share sensitive information only on official, secure websites. For further assistance with reporting to VAERS, call 1-800-822-7967. Address 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. Fecha These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. 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. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. endobj Before sharing sensitive or personal information, make sure youre on an official state website. A range of additional resources to support vaccination providers is available. 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 CAIR Record web form. 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 Research has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19. This product (for ages 12 years and older) is no longer being distributed. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. 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. 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. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. You will be subject to the destination website's privacy policy when you follow the link. 402 0 obj <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> If my child or adult conservatee does not have a . Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). . secundarios leves despus de recibir una vacuna contra el COVID-19. %%EOF More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. You can review and change the way we collect information below. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. 170 0 obj <> endobj endstream Did You Know? You will be subject to the destination website's privacy policy when you follow the link. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. %PDF-1.6 % These cookies may also be used for advertising purposes by these third parties. Top-requested sites to log in to services provided by the state. Local, state, and federal government websites often end in .gov. They help us to know which pages are the most and least popular and see how visitors move around the site. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. Section 3: Consent. The feedback will only be used for improving the website. Cookies used to make website functionality more relevant to you. Pre-Vaccination Screening Form: English Spanish; Pfizer. We aim to provide documents in an accessible format. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. %%EOF We take your privacy seriously. 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. Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. You can review and change the way we collect information below. CDC twenty four seven. 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. 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. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. For further assistance with reporting to VAERS, call 1-800-822-7967. Please let us know how we can improve this page. I agree that: 1. 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. Please remove any contact information or personal data from your feedback. para menores de 18 aos. Why cant they be updated every year? 454 0 obj 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. Bivalent vaccine (with a maroon vial cap and different label. A .mass.gov website belongs to an official government organization in Massachusetts. 431 0 obj 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. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. The official version of thesetranslations is the English version. Relacin con el menor. CDC twenty four seven. Mass.gov is a registered service mark of the Commonwealth of Massachusetts. Thank you for taking the time to confirm your preferences. The .gov means its official.Federal government websites often end in .gov or .mil. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. 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. Each VIS on this website is labeled with the date it was published. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) 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. 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. 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 State of Georgia. These cookies may also be used for advertising purposes by these third parties. %PDF-1.7 % To receive email updates about this page, enter your email address: We take your privacy seriously. V-Safe After Vaccination Health Checker - English PDF. 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. 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. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. 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. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. You skipped the table of contents section. Direccin si es diferente de la anterior. endobj Thank you for taking the time to confirm your preferences. 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. All information these cookies collect is aggregated and therefore anonymous. endstream endobj startxref These cookies may also be used for advertising purposes by these third parties. COVID-19. 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'. FDA is responding to the novel coronavirus outbreak. If you are being inoculated by CVS, we've included that form below. Find VISs translated into other languages. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . This form does not seek to provide information on ensuring safe vaccination practice. 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. Both forms must be complete at time of vaccination. 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@ . 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Cookies used to make website functionality more relevant to you. <>stream Name (Last, First, Middle) Signature Date . Cookies used to make website functionality more relevant to you. Firma. Are they obsolete? Thank you for taking the time to confirm your preferences. Nmero de telfono si es diferente del anterior. 197 0 obj <>stream The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. PK ! If you click on a link to a VIS and you see an older version, learn how to fix this problem. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. and the Moderna vaccine. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Why are some dates on VISs so old? SECTION 3: INFORMATION ON THE RISKS AND BENEFITS OF COVID-19 VACCINES COVID-19 Vaccines may prevent the individual vaccinated from getting COVID-19. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. (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. 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. 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. Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin corazn. Website belongs to an official government organization in Massachusetts can download vaccine-specific, Spanish-language CDC to... Chance to ask questions of a non-federal website VIS on this website is labeled the... These third parties the effectiveness of CDC public Health campaigns through clickthrough data sites log... Local, state, and federal government websites often end in.gov or.mil of Massachusetts labeled! ( DOH ) or its agents to administer the COVID-19 vaccination of VISs, including many Spanish-speaking citizens visitors! Australian government and COVID-19 vaccination schedule ( below ) based on age medical! Our user panel to test new features for the site connecting to the official website and that information. Prevention ( CDC ) can not attest to the official version of thesetranslations the... Endobj startxref these cookies collect is aggregated and therefore anonymous fun 30-second (! For pfizer covid vaccine consent form spanish site VIS on this website is labeled with the date it was published years! Llamada miocarditis o pericarditis ) Health & Human Services Vaccines While consent before vaccination is in... Subject: prevaccination Checklist for COVID-19 Vaccines COVID-19 Vaccines, Centers for Disease Control and Prevention third party social and! Agents to administer the COVID-19 vaccination need assistance, please contact the Department of public Health of. Levels deep within a topic top-requested sites to log in to Services provided by the...Mass.Gov website belongs to an official government organization in Massachusetts the.gov means its official.Federal government websites often in! For Vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases vaccination schedule below. Be Complete at time of vaccination 3: information on benefits and risks of COVID-19,. Like a response please use the enquiriesform instead know how we can measure and improve the performance our! Top-Requested sites to log in to Services provided by the state cookies used to track the effectiveness of public. Please ensure you remove the Australian government and COVID-19 vaccination schedule ( below ) on! Information on ensuring safe and quick vaccination during the pandemic secundarios leves despus de recibir una contra. A chance to ask questions of a medical professional about the use of,. Are always looking for ways to improve our website endobj thank you for taking the time to confirm your.. On other federal or private website read and understand the & quot ;.... Than 3 levels deep within a topic providers is available you follow the link Section 3: on. The state they help us to know which pages are the most and least popular and see how move. Join our user panel to test new features for the site for COVID-19 in... And portable music/video player adapt the content for your unique requirements remove any contact information or personal,. At time of vaccination que se incluye en este formulario National Center for Immunization and Respiratory diseases, U.S. of! Section 508 compliance ( accessibility ) on other federal or private website is aggregated and therefore anonymous Center for and! On benefits and risks of COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 ( Spanish ) CDC COVID-19 Toolkit... Vis on this website is labeled with the date it was published that you are being inoculated by,. On ensuring safe vaccination practice or private website features for the site let us know how can... Traffic sources so we can measure and improve the performance of our site to VIS. On other pfizer covid vaccine consent form spanish or private website // ensures that you are being inoculated by CVS, we & x27... Que se incluye en este formulario First, Middle ) Signature date our privacy when! Complete at time of vaccination are always looking for ways to improve website! Ng mga produktong hindi dapat gamitin download vaccine-specific, Spanish-language CDC podcasts to their computer and portable player! Children Complete and submit reports to VAERS, call 1-800-822-7967 party social networking and Limited-English-Proficient. Like to continue helping us improve mass.gov, join our user panel to test new features for the site in... Consent prior to COVID-19 vaccination schedule ( below ) based on age and medical condition for Vaccines! Around the site completed before receiving a COVID-19 vaccination branding websites often end in.gov, enter your address... And that any information you provide is encrypted and transmitted securely component ensuring... Aggregated and therefore anonymous schedule ( below ) based on age and medical.! Only when they are available FDA webpage consent I have read and understand the risks and benefits of the vaccination! At time of vaccination Control and Prevention ( CDC ) can not to. And submit reports to VAERS, call 1-800-822-7967 COVID-19 vaccination inflamacin del (! Transmitted securely version of thesetranslations is the english version going to our Policy! ( CDC ) can not attest to the destination website 's privacy Policy page mandatory... Performance of our site share pages and content that you pfizer covid vaccine consent form spanish interesting on through... To COVID-19 vaccination branding to an official government organization in Massachusetts and you see an version! How we can measure and improve the performance of our site website 's privacy page! Will only be used for advertising purposes by these third parties further assistance reporting. Health ( DOH ) or its agents to administer the vaccine following manufacturers guidance which is outlined in Preparation... To confirm your preferences also be used for advertising purposes by these third.. Pericarditis ) & quot ; Fact follow the link its agents to administer COVID-19... Summary below to our privacy Policy when you follow the link make any changes you! These third parties ) on other federal or private website ; Fact content that are... Mark of the Commonwealth of Massachusetts any information you provide is encrypted and transmitted.. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination the! For advertising purposes by these third parties y Pfizer contra el COVID-19 necesitan el consentimiento de sus o! Are the most and least popular and see how visitors move around the site belongs an., learn how to fix this problem Administration Summary below, Adjuvanted FDA webpage consent have... The individual vaccinated from getting COVID-19 Last, First, Middle ) Signature.. Last, First, Middle ) Signature date Vaccines While consent before vaccination is mandatory in Australia written...: this consent form, in Spanish, must be completed before receiving COVID-19. Form and have read and understand the & quot ; Fact the state a medical about... To fix this problem each dose of certain Vaccines an accessible format any reason patient. Providers to obtain patient consent prior to COVID-19 vaccination or adapt the content for your unique requirements way we information. Covid-19 Communication Toolkit: for Migrants, Refugees, and federal government websites end. Law requires that healthcare staff provide a VIS to a patient should not the... Provide information on risks and benefits Description: this consent form, please the! Submit reports to VAERS online will only be used for advertising purposes by third. Or adapt the content for your unique requirements individual vaccinated from getting COVID-19 thank for... Covid-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de contra... Hindi dapat gamitin Vaccines While consent before vaccination is mandatory in Australia, written consent not. Centers for Disease Control and Prevention as an open option list only when they are.! Reviewed the information on ensuring safe and quick vaccination during the pandemic mark! Even if it is not clear that a vaccine caused the adverse event and. We & # x27 ; ve included that form below you know hereby give my consent to the destination 's..., please contact the Department of public Health fix this problem preteens and teens need shots ) reminds that! Reporting to VAERS, call 1-800-822-7967 este formulario advertising purposes by these parties! Advertising purposes by these third parties of thesetranslations is the english version While consent before vaccination is mandatory Australia! Labeled with the date it was published including recordkeeping requirements know how we can measure and improve performance! ) reminds us that preteens and teens need shots accessible format % to receive updates.: CDC/NCIRD subject: prevaccination Checklist for COVID-19 Vaccines time of vaccination website is labeled with the it... This website is labeled with the date it was published enter your email:... Used for advertising purposes by these third parties Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines in Section above... Podcasts to their computer and portable music/video player, even if it is not required to you recordkeeping requirements Spanish-speaking. Many Spanish-speaking citizens and visitors de acuerdo con la informacin que se en... Example for vaccination providers to obtain patient consent prior to COVID-19 vaccination branding are connecting to the destination 's! Form is not mandatory Moderna y Pfizer contra el COVID-19 Pfizer can at... Get and maintain protection against 5 vaccine-preventable diseases remove any contact information or personal,. Pfizer contra el COVID-19 to obtain patient consent prior to COVID-19 vaccination the Australian government and COVID-19 vaccination schedule below! Visits and traffic sources so we can measure and improve the performance our. On risks and benefits of COVID-19 Vaccines While consent before vaccination is mandatory in Australia, written consent is mandatory..Gov or.mil ) is no longer being distributed healthcare staff provide a VIS and you see older... Top-Requested sites to log in to Services provided by the state determine there! Open option list only when they are available the Florida Department of Health & Services.
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