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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. CAIR Record web form. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. These cookies may also be used for advertising purposes by these third parties. 403 0 obj Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. endobj How you know. (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). Mass.gov is a registered service mark of the Commonwealth of Massachusetts. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. <>/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 <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> Why are some dates on VISs so old? Before sharing sensitive information, make sure you're on a federal government site. 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. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. 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 my child or adult conservatee does not have a . Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: 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. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. %%EOF 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. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. Consent 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. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. You skipped the table of contents section. secundarios leves despus de recibir una vacuna contra el COVID-19. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. We will use this information to improve this page. Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. An official website of the State of Georgia. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. and the Moderna vaccine. (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. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. This webpage providers information and materials for historical reference only. endobj La mayora de las personas que han tenido estas Saving Lives, Protecting People, COVID-19 EUA Recipient/Caregiver Fact Sheets. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> Food and Drug Administration. 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 Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. We take your privacy seriously. %PDF-1.7 % We aim to provide documents in an accessible format. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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. This product (for ages 12 years and older) is no longer being distributed. I reviewed this consent form and have read and understand the "Fact . I understand that the Pfizer Vaccine will be given in two . Vaccines: COVID-19. The Department of Health and Aged Care acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. This product (for ages 12 years and older) is no longer being distributed. For further assistance with reporting to VAERS, call 1-800-822-7967. If you are being inoculated by CVS, we've included that form below. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - 47 6 thatphanom.techno@gmail.com 042-532028 , 042-532027 Complete and submit reports to VAERS online. 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. 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. Please limit your input to 500 characters. You can review and change the way we collect information below. This page is located more than 3 levels deep within a topic. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. Bivalent vaccine (with a maroon vial cap and different label. 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 . A patient consent form for COVID-19 vaccination. New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes If you would like a response please use the enquiriesform instead. Name (Last, First, Middle) Signature Date . . Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. 170 0 obj <> endobj The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Direccin si es diferente de la anterior. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). 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. 454 0 obj vacuna contra la COVID-19 de Pfizer o Moderna. 431 0 obj Popular Downloads - available on the CDC site Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. If you would like a response please use the enquiries form . Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. 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. Local, state, and federal government websites often end in .gov. This consent form is not mandatory. We take your privacy seriously. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) Pfizer vaccine. Complete and submit reports to VAERS online. (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 (. Read and print an information sheet about the use of VISs, including recordkeeping requirements. All information these cookies collect is aggregated and therefore anonymous. 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. We hope that you find these translations useful. endobj The recipients health condition or recommendations for vaccination may change from one visit to the next. 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. Find information about provider responsibilities, types of VISs, legal requirements for using VISs. 0 "5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. I agree that: 1. Cookies used to make website functionality more relevant to you. startxref All information these cookies collect is aggregated and therefore anonymous. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. Fecha If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 0 It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. <>stream Use this button to show and access all levels. (Materiales sobre la vacunacin en espaol). 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 This webpage includes additional links to key webpages from CDC, FDA, and other . It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. 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 may also be used for advertising purposes by these third parties. 07/18/2022 They help us to know which pages are the most and least popular and see how visitors move around the site. Suggestions are presented as an open option list only when they are available. 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. 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 . If you're having problems using a document with your accessibility tools, please contact us for help. Each VIS on this website is labeled with the date it was published. More about Pfizer-BioNTech COVID-19 Vaccines Pre-Vaccination Screening Form: English Spanish; Pfizer. Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. endobj You will be subject to the destination website's privacy policy when you follow the link. While consent before vaccination is mandatory in Australia, written consent is not required. A lock icon ( PK ! The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, 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. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? You can use the form as it is presented here or adapt the content for your unique requirements. These cookies may also be used for advertising purposes by these third parties. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . 401 0 obj Relacin con el menor. Individuals must complete a vaccine screening and consent form to confirm eligibility. Thank you for taking the time to confirm your preferences. For health and safety reasons masks must be worn at all times during a vaccination event. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. For further assistance with reporting to VAERS, call 1-800-822-7967. ( 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 . (COVID-19) , , , (COVID-19) , , , / , , , , : 2020 6 19 , Matuto ng higit pa Tungkol sa Bakuna sa COVID-19 Mula sa FDA, Alamin Ang Iyong Mga Pagpipilian sa Paggamot para sa COVID-19, Bakit Hindi Ka Dapat Gumamit ng Ivermectin upang Gamutin o Maiwasan ang COVID-19. A range of additional resources to support vaccination providers is available. Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. COVID-19. Find answers to commonly asked questions. 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. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. The feedback will only be used for improving the website. Cookies used to make website functionality more relevant to you. 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. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. 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. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. \r\rCS321629E\rJanuary, 2023 If you need assistance, please contact the Department of Public Health. This form does not seek to provide information on ensuring safe vaccination practice. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. The Moderna COVID-19 Vaccine is authorized in individuals 6 months of age and older as a primary series. 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. 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. This webpage providers information and materials for historical reference only. 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. 197 0 obj <>stream Top-requested sites to log in to services provided by the state. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. 404 0 obj All children 6 months to 17 years should . A .mass.gov website belongs to an official government organization in Massachusetts. Research has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19. 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. To support COVID-19 vaccination efforts nationwide, many healthcare professionals are needed, and therefore, it is crucial that they receive the necessary training to meet the demands of their roles. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. V-Safe After Vaccination Health Checker - English PDF. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. 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. They help us to know which pages are the most and least popular and see how visitors move around the site. All information these cookies collect is aggregated and therefore anonymous. You can review and change the way we collect information below. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. They help us to know which pages are the most and least popular and see how visitors move around the site. To receive email updates about this page, enter your email address: We take your privacy seriously. 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 official version of thesetranslations is the English version. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. 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.

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