Share sensitive information only on official, secure websites. 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. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - We take your privacy seriously. You will be subject to the destination website's privacy policy when you follow the link. Cookies used to make website functionality more relevant to you. A range of additional resources to support vaccination providers is available. FDA is responding to the novel coronavirus outbreak. 404 0 obj This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. This product (for ages 12 years and older) is no longer being distributed. We take your privacy seriously. endobj How you know. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. 0 Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. Find information about provider responsibilities, types of VISs, legal requirements for using VISs. Cookies used to make website functionality more relevant to you. 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. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. A lock icon ( What if a recommendation for a vaccine changes but no updated VIS is available? More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. We will use this information to improve this page. and the Moderna vaccine. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. 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. Cookies used to make website functionality more relevant to you. 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" ). They help us to know which pages are the most and least popular and see how visitors move around the site. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. CDC twenty four seven. Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. All information these cookies collect is aggregated and therefore anonymous. Food and Drug Administration. CDC twenty four seven. Name (Last, First, Middle) Signature Date . You skipped the table of contents section. Pfizer's COVID-19 Vaccine Consent Form ( English / Spanish) Moderna's COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine . To receive email updates about this page, enter your email address: We take your privacy seriously. \r\rCS321629E\rJanuary, 2023 PK ! There are different fact sheets for different age groups. Thank you for taking the time to confirm your preferences. COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. Please limit your input to 500 characters. 170 0 obj <> endobj I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. ) or https:// means youve safely connected to the official website. I understand that the Pfizer Vaccine will be given in two . Why are some dates on VISs so old? 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. You can review and change the way we collect information below. Thank you for taking the time to confirm your preferences. An official website of the State of Georgia. (Materiales sobre la vacunacin en espaol). 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. La mayora de las personas que han tenido estas State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. . endobj Help us improve health.gov.au. <>stream SECTION 3: INFORMATION ON THE RISKS AND BENEFITS OF COVID-19 VACCINES COVID-19 Vaccines may prevent the individual vaccinated from getting COVID-19. Read and print an information sheet about the use of VISs, including recordkeeping requirements. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. You will be subject to the destination website's privacy policy when you follow the link. Local, state, and federal government websites often end in .gov. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. endobj secundarios leves despus de recibir una vacuna contra el COVID-19. For further assistance with reporting to VAERS, call 1-800-822-7967. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. startxref Address if different from above . 403 0 obj All information these cookies collect is aggregated and therefore anonymous. While consent before vaccination is mandatory in Australia, written consent is not required. We aim to provide documents in an accessible format. 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. 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 <. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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@ . Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) These cookies may also be used for advertising purposes by these third parties. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. Find answers to commonly asked questions. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. Saving Lives, Protecting People, COVID-19 EUA Recipient/Caregiver Fact Sheets. I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. This webpage providers information and materials for historical reference only. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. More about Pfizer-BioNTech COVID-19 Vaccines You can review and change the way we collect information below. Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. We hope that you find these translations useful. %%EOF If you are being inoculated by CVS, we've included that form below. para menores de 18 aos. For health and safety reasons masks must be worn at all times during a vaccination event. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. Some page levels are currently hidden. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . Please let us know how we can improve this page. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. I reviewed this consent form and have read and understand the "Fact . CAIR Record web form. . Complete and submit reports to VAERS online. Complete and submit reports to VAERS online. 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 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). 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. They help us to know which pages are the most and least popular and see how visitors move around the site. 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. %PDF-1.7 % V-Safe After Vaccination Health Checker - English PDF. Mass.gov is a registered service mark of the Commonwealth of Massachusetts. . He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. The recipients health condition or recommendations for vaccination may change from one visit to the next. <>/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 0 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'$0H0_At9HBd:'u )"dAza|DQL(-I. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Phone Number if different from above . CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . You can review and change the way we collect information below. While the agency has attempted to obtain translations that are as faithful as possible to the English version, we recognize that the translated versions may not be as precise, clear, or complete as the English version. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. Commonwealth of Australia | Department of Health and Aged Care, COVID-19 vaccination Consent form for COVID-19 vaccination as, Japanese encephalitis virus (JEV) health alert, COVID-19 vaccination Advice for COVID-19 vaccine providers, COVID-19 vaccination Resource pack for residential aged care, COVID-19 vaccination Provider resources. Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . "5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P The official version of thesetranslations is the English version. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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 need to go back and make any changes, you can always do so by going to our Privacy Policy page. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. What are VISs? 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. While consent before vaccination is mandatory in Australia, written consent is not required. They help us to know which pages are the most and least popular and see how visitors move around the site. Bivalent vaccine (with a maroon vial cap and different label. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. endobj This product (for ages 12 years and older) is no longer being distributed. Scroll down to access downloads and media. Australian Government Department of Health and Aged Care. 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 This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. (FDA) ? 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. endstream 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. vacuna contra la COVID-19 de Pfizer o Moderna. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? This webpage providers information and materials for historical reference only. (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). Form below Summary below for the site can review and change the way we collect information below Effective Date 1/04/2021... Checklist for COVID-19 Vaccines information for healthcare Professionals Author: CDC/NCIRD subject: Checklist.: Monovalent Pfizer-BioNTech COVID-19 Vaccines you can always do so by going to our privacy policy you! 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