All information these cookies collect is aggregated and therefore anonymous. (Check back as we will continue to. An official website of the United States government, : This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Both forms must be complete at time of vaccination. If you would like a response please use the enquiries form . Suggestions are presented as an open option list only when they are available. All information these cookies collect is aggregated and therefore anonymous. If my child or adult conservatee does not have a . 170 0 obj <> endobj Follow the COVID-19 vaccination schedule (below) based on age and medical condition. 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. Thank you for taking the time to confirm your preferences. 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. Food and Drug Administration. vacuna contra la COVID-19 de Pfizer o Moderna. If you are being inoculated by CVS, we've included that form below. I understand that This product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA . Some page levels are currently hidden. 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. (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 (. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). Pfizer's COVID-19 Vaccine Consent Form ( English / Spanish) Moderna's COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine . I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. 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. Please limit your input to 500 characters. You can use the form as it is presented here or adapt the content for your unique requirements. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) 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. V-Safe After Vaccination Health Checker - English PDF. 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. 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 <. 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). . endobj Find VISs translated into other languages. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. Did You Know? The recipients health condition or recommendations for vaccination may change from one visit to the next. Please remove any contact information or personal data from your feedback. 0 We aim to provide documents in an accessible format. Share sensitive information only on official, secure websites. Consentimiento de vacuna contra la COVID-19. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. Pfizer vaccine. 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@ . Address if different from above . If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. To receive email updates about this page, enter your email address: We take your privacy seriously. 454 0 obj Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. If you would like a response please use the enquiriesform instead. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. You can review and change the way we collect information below. A lock icon ( Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. 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. These cookies may also be used for advertising purposes by these third parties. PK ! \r\rCS321629E\rJanuary, 2023 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. Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). We take your privacy seriously. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - 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. Individuals must complete a vaccine screening and consent form to confirm eligibility. 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 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 State of Georgia. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. For further assistance with reporting to VAERS, call 1-800-822-7967. CDC twenty four seven. 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. 404 0 obj If you click on a link to a VIS and you see an older version, learn how to fix this problem. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. 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. Are they obsolete? La mayora de las personas que han tenido estas 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. 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. English Description: This consent form is not mandatory. %PDF-1.7 % These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Top-requested sites to log in to services provided by the state. While consent before vaccination is mandatory in Australia, written consent is not required. 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. 402 0 obj I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. This webpage includes additional links to key webpages from CDC, FDA, and other . Complete and submit reports to VAERS online. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 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. 0 This product (for ages 12 years and older) is no longer being distributed. This page is located more than 3 levels deep within a topic. 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. 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. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to While most patients may speak English, they may better understand about vaccines and vaccine-preventable diseases when the information is written in Spanish. Phone Number if different from above . The site is secure. Saving Lives, Protecting People, National Center for Immunization and Respiratory Diseases, Use of COVID-19 Vaccines in the U.S.: Appendices, FAQs for the Interim Clinical Considerations, Myocarditis and Pericarditis Considerations, Jurisdictions: Vaccinating Older Adults and People with Disabilities, Vaccination Sites: Vaccinating Older Adults and People with Disabilities, Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities, Vaccines for Children Program vs. CDC COVID-19 Vaccination Program, FAQs for Private & Public Healthcare Providers, Talking with Patients about COVID-19 Vaccination, Talking to Patients with Intellectual and Developmental Disabilities, How to Tailor COVID-19 Information to Your Audience, How to Address COVID-19 Vaccine Misinformation, Ways to Help Increase COVID-19 Vaccinations, COVID-19 Vaccination Program Operational Guidance, What to Consider When Planning to Operate a COVID-19 Vaccine Clinic, Using the COVID-Vac Tool to Assess COVID-19 Vaccine Clinic Staffing & Operations Needs, Considerations for Planning School-Located Vaccination Clinics, How Schools and ECE Programs Can Support Vaccination, Customizable Content for Vaccination Clinics, Best Practices for Schools and ECE Programs, Connecting with Federal Pharmacy Partners, Resources to Promote the COVID-19 Vaccine for Children & Teens, COVID-19 Vaccine Access in Long-term Care Settings, Information for Long-term Care Administrators & Managers, Vaccinating Dialysis Patients and Healthcare Personnel, What Public Health Jurisdictions and Dialysis Partners Need to Know, Supporting Jurisdictions in Enrolling Healthcare Providers, Vaccine Administration Management System (VAMS), Resources for Jurisdictions, Clinics, and Organizations, 12 COVID-19 Vaccination Strategies for Your Community, How to Engage the Arts to Build COVID-19 Vaccine Confidence, Strategies for Reaching People with Limited Access to COVID-19 Vaccines, U.S. Department of Health & Human Services. The feedback will only be used for improving the website. secundarios leves despus de recibir una vacuna contra el COVID-19. CDC twenty four seven. We pay our respects to them and their cultures, and to elders both past and present. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 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. Thank you for your website feedback! Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. Thank you for taking the time to confirm your preferences. Complete and submit reports to VAERS online. endobj A .mass.gov website belongs to an official government organization in Massachusetts. For health and safety reasons masks must be worn at all times during a vaccination event. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- FDA is responding to the novel coronavirus outbreak. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> You skipped the table of contents section. These cookies may also be used for advertising purposes by these third parties. Before sharing sensitive information, make sure you're on a federal government site. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? We will use this information to improve this page. CAIR Record web form. Each VIS on this website is labeled with the date it was published. endstream endobj startxref Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. Please limit your input to 500 characters. hbbd```b``V D}IN0Y They help us to know which pages are the most and least popular and see how visitors move around the site.