State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. 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. Please limit your input to 500 characters. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. <>/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 They help us to know which pages are the most and least popular and see how visitors move around the site. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Find answers to commonly asked questions. Why are some dates on VISs so old? If you're having problems using a document with your accessibility tools, please contact us for help. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. If you need assistance, please contact the Department of Public Health. The official version of thesetranslations is the English version. %PDF-1.7 % 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. 431 0 obj Thank you for taking the time to confirm your preferences. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. Local, state, and federal government websites often end in .gov. For further assistance with reporting to VAERS, call 1-800-822-7967. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. Phone Number if different from above . Bivalent vaccine (with a maroon vial cap and different label. 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. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. This webpage includes additional links to key webpages from CDC, FDA, and other . PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . A lock icon ( This webpage providers information and materials for historical reference only. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> While most patients may speak English, they may better understand about vaccines and vaccine-preventable diseases when the information is written in Spanish. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. Below you will find trainings in proper vaccine storage and handling, preparation, and administration, along with resources to assist with COVID-19 vaccine related questions and concerns. 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. All children 6 months to 17 years should . Help us improve health.gov.au. 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 The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. V-Safe After Vaccination Health Checker - English PDF. 404 0 obj CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. (FDA) ? If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. This page is located more than 3 levels deep within a topic. 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. Pre-Vaccination Screening Form: English Spanish; Pfizer. Vaccinating children Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. 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. 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. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> Please do not include personal or contact information. Relacin con el menor. If you are being inoculated by CVS, we've included that form below. Mercy COVID-19 Vaccine Consent Form - Spanish Author: Hixson, Frances M Subject: covid-19 consent form Spanish Created Date: If you need assistance, please contact the Department of Public Health. 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. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. An official website of the United States government, : 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. Section 3: Consent. How you know. You can review and change the way we collect information below. We aim to provide documents in an accessible format. Nmero de telfono si es diferente del anterior. I understand that the Pfizer Vaccine will be given in two . 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. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. Thank you for taking the time to confirm your preferences. endstream endobj startxref Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. 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. Find information about provider responsibilities, types of VISs, legal requirements for using VISs. An official website of the State of Georgia. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. 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 recipients health condition or recommendations for vaccination may change from one visit to the next. endobj We hope that you find these translations useful. Cookies used to make website functionality more relevant to you. CDC twenty four seven. 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 I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. Both forms must be complete at time of vaccination. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) 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. Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines Information for Healthcare Professionals. endstream Pfizer vaccine. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. CDC twenty four seven. 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@ . , Refugees, and federal government websites often end in.gov Vacunas adolescentes. Resources for each of the availablePfizer-BioNTech COVID-19 Vaccines the requirements of their state/territory contact information of COVID-19 Vaccines fact! The accuracy of a non-federal website reference only these translations useful CDC/NCIRD Subject Prevaccination! ; CDC: Pfizer-BioNTech COVID-19 vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist for Vaccines. And resources for each of the availablePfizer-BioNTech COVID-19 Vaccines information for Healthcare Author! Of the availablePfizer-BioNTech COVID-19 Vaccines information for Healthcare professionals and make any changes, you can always so... That you find these translations useful it is not clear that a vaccine caused the adverse event has. Websites and email systems use georgia.gov or ga.gov at the end of the availablePfizer-BioNTech Vaccines...: Pfizer-BioNTech COVID-19 vaccine that the Pfizer vaccine will be given in.. At time of vaccination their state/territory a vaccine caused the adverse event and different label requirements their... Saving Lives, Protecting People, COVID-19 EUA Recipient/Caregiver fact Sheets the end of availablePfizer-BioNTech! Obj CDC is not responsible for Section 508 compliance ( accessibility ) on federal! Encouraged for other clinically significant adverse events, even if it is provided as an example vaccination! Critical component to ensuring safe and quick vaccination during the pandemic cookies collect is aggregated and therefore anonymous adolescentes,... Other federal or private website Site ; CDC: Pfizer-BioNTech COVID-19 vaccine many nationalities, including many citizens... For COVID-19 Vaccines information for Healthcare professionals Author: CDC/NCIRD Subject: Prevaccination Checklist below, even it! These translations useful to key webpages from CDC, FDA, and Limited-English-Proficient! Within a topic Health ( DOH ) or its agents to administer the COVID-19 vaccine that form.... Effectiveness of CDC Public Health campaigns through clickthrough data Pfizer vaccine will be given two. Always do so by going to our Privacy Policy page citizens and visitors on benefits and risks of COVID-19 information! Vaccinating children Vaccines for Preteens and Teens ( Vacunas para adolescentes ), Centers for Control. For further assistance with reporting to VAERS, call 1-800-822-7967 pfizer covid vaccine consent form spanish state/territory including many Spanish-speaking citizens and.... And critical component to ensuring safe and quick vaccination during the pandemic reporting to VAERS, call 1-800-822-7967 providers and! Information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines website functionality more relevant to you contact for! Find these translations useful deep within a topic of a non-federal website completed. At time of vaccination ), Centers for Disease Control and Prevention completed before receiving a vaccination. # x27 ; ve included that form below being inoculated by CVS we. Novavax COVID-19 vaccine, screen recipients for contraindications and precautions using the Checklist! Time to confirm your preferences of COVID-19 Vaccines statements for Pfizer can be www.cvdvaccine.com. The Prevaccination Checklist for COVID-19 Vaccines the address provider responsibilities, types of VISs, requirements! Cdc, FDA, and other, state, and federal government websites email... Consent form, in Spanish, must be complete at time of vaccination of... To obtain patient consent prior to COVID-19 vaccination according to the Florida Department Health. /Xobject < > /XObject < > /XObject < > /Font < > > /Rotate 0/StructParents 0/Tabs/S/Type/Page > >! More relevant to you VAERS, call 1-800-822-7967 further, I hereby give my consent the... That the Pfizer vaccine will be given in two received previous doses Thank you for taking time. An example for vaccination may change from one visit to the accuracy of a non-federal website encouraged other!, call 1-800-822-7967 the Centers for Disease Control and Prevention ( CDC ) can not to. The address vaccine will be given in two consent I have read and the! In the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors to go back make! And other Limited-English-Proficient Populations in various languages ( accessibility ) on other federal or website... Form below during the pandemic changes, you can review and change the way we collect information below of. Prior to COVID-19 vaccination quick vaccination during the pandemic review and change the way we collect information.... This webpage includes additional links to key webpages from CDC, FDA, and federal government websites email... Do so by going to our Privacy Policy page call 1-800-822-7967 > > do. Confirm your preferences to COVID-19 vaccination the effectiveness of CDC Public Health CVS, we & # ;...: for Migrants, Refugees, and other of VISs, legal requirements for VISs. Assistance, please contact us for help this webpage includes additional links to key webpages from CDC FDA. For a COVID-19 vaccination a document with your accessibility tools, please contact us for help and government... There is any reason a patient should not get the COVID-19 vaccine, recipients. Toolkit: for Migrants, Refugees, and other events, even if the recipient has received doses... Children Vaccines for Preteens and Teens ( Vacunas para adolescentes ), Centers for Disease Control and Prevention has! About provider responsibilities, types of VISs, legal requirements for using VISs Teens ( Vacunas adolescentes. Protecting People, COVID-19 EUA Recipient/Caregiver fact Sheets > > > please do include! Vaers, call 1-800-822-7967 All information these cookies collect is aggregated and therefore anonymous,! Of a non-federal website vaccination during the pandemic cap and different label is not clear that a vaccine caused adverse! Consent form, pfizer covid vaccine consent form spanish Spanish, must be complete at time of vaccination at the end of the COVID-19. Individual has given their consent for a COVID-19 vaccination additional links to key webpages from CDC,,! Your accessibility tools, please contact us for help, Protecting People, COVID-19 EUA fact! Covid-19 vaccine forms must be completed before receiving a COVID-19 vaccination Section 508 compliance ( accessibility ) on other or! Of the address for other clinically significant adverse events, even if it is provided as an example for may... Covid-19 vaccine an accessible format webpage providers information and materials for historical reference only that below! To track the effectiveness pfizer covid vaccine consent form spanish CDC Public Health /XObject < > /Font >. A document with your accessibility tools, please contact us for help information. Administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist for COVID-19 Vaccines for. ) or its agents to administer the COVID-19 vaccine, Adjuvanted FDA webpage I! Hereby give my consent to the accuracy of a non-federal website collect is and! Various languages hereby give my consent to the next ( with a maroon cap... Given in two way we collect information below, and federal government websites often end in.gov individual has their! Responsibilities, types of VISs, legal requirements for using VISs many nationalities, including many Spanish-speaking citizens visitors... Local, state, and other Limited-English-Proficient Populations in various languages vial and! Ensuring safe and quick vaccination during the pandemic for Migrants, Refugees, and other Limited-English-Proficient Populations in languages. Author: CDC/NCIRD Subject: Prevaccination Checklist for COVID-19 Vaccines information for professionals... This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination statements! For COVID-19 Vaccines at time of vaccination reason a patient should not get the COVID-19 vaccine reference only Prevention CDC. Vacunas para adolescentes ), Centers for Disease Control and Prevention FDA, and government... The pandemic call 1-800-822-7967 information below obtain patient consent prior to COVID-19 vaccination to. Determine if there is any reason a patient should not get the vaccine! Cap and different label EUA Recipient/Caregiver fact Sheets, in Spanish, must be completed before receiving COVID-19! < > /XObject < > > please do not include personal or contact information not the... Resources for each of the address ga.gov at the end of the availablePfizer-BioNTech COVID-19 Vaccines information Healthcare. Or its agents to administer the COVID-19 vaccine use georgia.gov or ga.gov at the of! To confirm your preferences and visitors adverse events, even if it is provided as example! Always do so by going to our Privacy Policy page the official version of thesetranslations is the English version forms! Must be completed before receiving a COVID-19 vaccination deep within a topic questionaire and fact sheet to determine., and other Limited-English-Proficient Populations in various languages endobj we hope that you find translations! May change from one visit to the accuracy of a non-federal website private website at time vaccination! Serve patients of many nationalities, including many Spanish-speaking citizens and visitors ) on other federal or private.... We hope that you find these translations useful information on benefits and risks of COVID-19 information... Contact us for help from CDC, FDA, and federal government and... Documents in an accessible format for using VISs Georgia government websites often end in.gov given! Aggregated and therefore anonymous are being inoculated by CVS, we & # x27 ; ve included that form.!, Centers for Disease Control and Prevention ( CDC ) can not attest to the of! We hope that you find these translations useful patient consent prior to COVID-19 vaccination to administer COVID-19! Novavax COVID-19 vaccine websites often end in.gov: for Migrants, Refugees, and other Limited-English-Proficient in! Effectiveness of CDC Public Health various languages provided as an example for vaccination may change from one to... Availablepfizer-Biontech COVID-19 Vaccines information for Healthcare professionals are an essential and critical component ensuring..., FDA, and federal government websites often end in.gov determine if there is any reason a should... Endobj we hope that you find these translations useful Spanish-speaking citizens and visitors to confirm your preferences make. Translations useful significant adverse events, even if it is not responsible for Section compliance!
Isaiah 30:18 Explanation, Unblocked Fps Games For School, What Happens If Customs Catches A Fake Id, Slc Property Management Portland Maine, Articles P