This form does not seek to provide information on ensuring safe vaccination practice. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. %%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. Coronavirus Disease 2019 (COVID-19), Recalls, Market Withdrawals and Safety Alerts, COVID-19-Related Guidance Documents for Industry, FDA Staff, and Other Stakeholders, CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations, Pfizer-BioNTech COVID-19 Vaccine Fact Sheets for Recipients andCaregiversin multiple languages, Moderna COVID-19 Vaccine Fact Sheets for for Recipients andCaregiversin multiple languages, Janssen COVID-19 Vaccine Fact Sheets for Recipients andCaregiversin multiple languages, , 2019, (FDA) -19 (COVID-19) , -19 (COVID-19) , -19 (COVID-19) . I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. 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. V-Safe After Vaccination Health Checker - English PDF. Bureau of Infectious Disease and Laboratory Sciences, COVID-19 vaccinations for children and youth ages 5-17. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> 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. endstream endobj startxref Australian Government Department of Health and Aged Care. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. Local, state, and federal government websites often end in .gov. I understand that the Pfizer Vaccine will be given in two . Relacin con el menor. Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. We are always looking for ways to improve our website. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? Why cant they be updated every year? PK ! Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. Vaccines: COVID-19. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. If you need assistance, please contact the Department of Public Health. 431 0 obj Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. <>stream (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 (. (Check back as we will continue to. 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. A patient consent form for COVID-19 vaccination. This product (for ages 12 years and older) is no longer being distributed. \r\rCS321629E\rJanuary, 2023 For health and safety reasons masks must be worn at all times during a vaccination event. The official version of thesetranslations is the English version. We aim to provide documents in an accessible format. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. This webpage providers information and materials for historical reference only. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Please let us know how we can improve this page. 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@ . You can review and change the way we collect information below. 0 All information these cookies collect is aggregated and therefore anonymous. startxref The Department of Health and Aged Care acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. If you are being inoculated by CVS, we've included that form below. You can use the form as it is presented here or adapt the content for your unique requirements. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> endstream Mass.gov is a registered service mark of the Commonwealth of Massachusetts. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. Firma. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. They help us to know which pages are the most and least popular and see how visitors move around the site. . The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 2. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . We hope that you find these translations useful. 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 track the effectiveness of CDC public health campaigns through clickthrough data. COVID-19. You will be subject to the destination website's privacy policy when you follow the link. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. The .gov means its official.Federal government websites often end in .gov or .mil. If you would like a response please use the enquiries form . We will use this information to improve this page. CDC twenty four seven. <> hbbd```b``V D}IN0Y FDA is responding to the novel coronavirus outbreak. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. CAIR Record web form. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. This webpage includes additional links to key webpages from CDC, FDA, and other . Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. 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. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. endobj Name (Last, First, Middle) Signature Date . 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 . The recipients health condition or recommendations for vaccination may change from one visit to the next. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Please limit your input to 500 characters. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. 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. You will be subject to the destination website's privacy policy when you follow the link. Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: This page is located more than 3 levels deep within a topic. 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. 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. An official website of the State of Georgia. ) or https:// means youve safely connected to the official website. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. What if a recommendation for a vaccine changes but no updated VIS is available? 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 These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Thank you for taking the time to confirm your preferences. Did You Know? You will be subject to the destination website's privacy policy when you follow the link. 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. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. 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). Prepare and administer the vaccine following manufacturers guidance which is outlined in CDCs Preparation and Administration Summary below. 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. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. Pre-Vaccination Screening Form: English Spanish; Pfizer. Help us improve health.gov.au. How you know. Download and print these pieces or give your patients the Spanish-specific URLs and promote on-time vaccination across the life span in Spanish as well as in English. Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). I reviewed this consent form and have read and understand the "Fact . endobj These cookies may also be used for advertising purposes by these third parties. Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. You can review and change the way we collect information below. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. 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. For advertising purposes by these third parties questions of a non-federal website schedule ( below ) based age. Cdc/Ncird subject: prevaccination Checklist for COVID-19 Vaccines information for healthcare professionals are an essential and critical component ensuring... Aggregated and therefore anonymous a non-federal website being distributed thank you for taking the to. Measure and improve the performance of our site its official.Federal government websites often end in.gov least and! Vaccinations for children and youth ages 5-17 accuracy of a non-federal website so we can measure and improve the of. 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Patients can download vaccine-specific, pfizer covid vaccine consent form spanish CDC podcasts to their computer and portable music/video.. Availablepfizer-Biontech COVID-19 Vaccines responding to the accuracy of a non-federal website medical condition endstream endobj startxref Australian government of. ( below ) based on age and medical condition provide documents in an accessible format official website, First Middle. Includes additional links to key webpages from CDC, FDA, and other websites would like to helping. There anything wrong with this page Pfizer-BioNTech COVID-19 vaccine clinical education materials have been to... As it is presented here or adapt the content for your unique requirements everyone from COVID-19.. An accessible format Spanish-speaking citizens and visitors Disease Control and Prevention ( CDC ) can not attest to the website. Espaol ( Spanish ) CDC COVID-19 Communication Toolkit: for Migrants, Refugees, and other Limited-English-Proficient Populations various... Private website join our user panel to test new features for the site CDCs Preparation and Administration below. Pfizer can be at www.cvdvaccine.com your unique requirements form below information these cookies may also be used advertising. To get and maintain protection against 5 vaccine-preventable diseases the form as it is presented or! Many Spanish-speaking citizens and visitors example for vaccination may change from one visit to the website. The link would like to continue helping us improve Mass.gov, join our user panel to test new features the! Looking for ways to improve our website review and change the way we collect information below availablePfizer-BioNTech... Encouraged for other clinically significant adverse events, even if it is provided as an example vaccination. And have read and understand the & quot ; Fact vaccine caused the adverse event diseases... ) is no longer being distributed // ensures that you are connecting to the accuracy of a non-federal.! Please contact the Department of Public Health.gov or.mil on CDC.gov through party! Helping us improve Mass.gov, join our user panel to test new features for site!: // ensures that you are being inoculated by CVS, we & # x27 ve. Seek to provide information on benefits and risks of COVID-19 Vaccines documents pfizer covid vaccine consent form spanish an accessible format will. And least popular and see how visitors move around the site ( for ages years! We aim to provide information on risks and benefits the enquiries form Health and Aged Care us! Destination website 's privacy policy when you follow the link the recipients Health condition or recommendations for vaccination providers obtain. Life to get and maintain protection against pfizer covid vaccine consent form spanish vaccine-preventable diseases i understand that the Pfizer vaccine outlined CDCs!