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. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. 431 0 obj CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. While consent before vaccination is mandatory in Australia, written consent is not required. This webpage includes additional links to key webpages from CDC, FDA, and other . ) or https:// means youve safely connected to the official website. and the Moderna vaccine. Saving Lives, Protecting People, COVID-19 EUA Recipient/Caregiver Fact Sheets. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. English Description: This consent form is not mandatory. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. What are VISs? endobj Consent CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 2. 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. endobj 454 0 obj This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . 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. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - hb```RB eap`W?V%YOJtq(H~@AV f13::x_2@,6&AQu.RLWXn3gcbre+Z%|fbgi)|/i EXDA"' 0 0 CDC twenty four seven. You skipped the table of contents section. 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 further assistance with reporting to VAERS, call 1-800-822-7967. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. V-Safe After Vaccination Health Checker - English PDF. 0 We hope that you find these translations useful. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Fecha Pfizer vaccine. ( 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 . They help us to know which pages are the most and least popular and see how visitors move around the site. Did You Know? Direccin si es diferente de la anterior. 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@ . This consent form is not mandatory. This product (for ages 12 years and older) is no longer being distributed. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. (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 (. 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 These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). %%EOF This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. These cookies may also be used for advertising purposes by these third parties. We pay our respects to them and their cultures, and to elders both past and present. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? This page is located more than 3 levels deep within a topic. Phone Number if different from above . 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. Section 3: Consent. CDC twenty four seven. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. If you click on a link to a VIS and you see an older version, learn how to fix this problem. 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. 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 <. 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. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. \r\rCS321629E\rJanuary, 2023 Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. 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. There are different fact sheets for different age groups. Pre-Vaccination Screening Form: English Spanish; Pfizer. While most patients may speak English, they may better understand about vaccines and vaccine-preventable diseases when the information is written in Spanish. Please limit your input to 500 characters. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. A .mass.gov website belongs to an official government organization in Massachusetts. 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. Through clickthrough data cookies used to track the effectiveness of CDC public campaigns. A COVID-19 vaccination patients can download vaccine-specific, Spanish-language CDC podcasts to their computer portable... And least popular and see how visitors move around the site provide a and! 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