"5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P A .mass.gov website belongs to an official government organization in Massachusetts. Complete and submit reports to VAERS online. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. They help us to know which pages are the most and least popular and see how visitors move around the site. 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 . Vaccinating children Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? For further assistance with reporting to VAERS, call 1-800-822-7967. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. endstream endobj startxref New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes Nmero de telfono si es diferente del anterior. Local, state, and federal government websites often end in .gov. If you click on a link to a VIS and you see an older version, learn how to fix this problem. 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. Each VIS on this website is labeled with the date it was published. This page is located more than 3 levels deep within a topic. 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. startxref Suggestions are presented as an open option list only when they are available. An official website of the United States government, : 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. 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. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. CDC twenty four seven. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. COVID-19. Both forms must be complete at time of vaccination. 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. I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech or Moderna COVID-19 vaccine and have reviewed and agree to the information included in this form. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). and the Moderna vaccine. The Moderna COVID-19 Vaccine is authorized in individuals 6 months of age and older as a primary series. What are VISs? These cookies may also be used for advertising purposes by these third parties. Thank you for taking the time to confirm your preferences. Find answers to commonly asked questions. 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. Thank you for your website feedback! These cookies may also be used for advertising purposes by these third parties. 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. All information these cookies collect is aggregated and therefore anonymous. (FDA) ? Popular Downloads - available on the CDC site More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. Complete and submit reports to VAERS online. 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. State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. Section 3: Consent. What if a recommendation for a vaccine changes but no updated VIS is available? CDC twenty four seven. You will be subject to the destination website's privacy policy when you follow the link. The site is secure. Cookies used to make website functionality more relevant to you. Thank you for taking the time to confirm your preferences. V-Safe After Vaccination Health Checker - English PDF. endstream 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. Direccin si es diferente de la anterior. (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 (. Please do not include personal or contact information. 402 0 obj 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. ( 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 . An official website of the State of Georgia. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. A patient consent form for COVID-19 vaccination. 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. We pay our respects to them and their cultures, and to elders both past and present. endobj Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. Ang iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin? hbbd```b``V D}IN0Y If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. endobj (Materiales sobre la vacunacin en espaol). 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. 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. 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. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. They help us to know which pages are the most and least popular and see how visitors move around the site. <>stream You can use the form as it is presented here or adapt the content for your unique requirements. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- 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) . En espaol ) to track the effectiveness of CDC public health campaigns through clickthrough data hindi dapat?! 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Click on a link to a VIS to a patient, parent or! Vaers, call 1-800-822-7967 time to confirm your preferences to fix this problem Moderna y Pfizer contra el.... Systems use georgia.gov or ga.gov at the end of the address thank you for taking time! Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin corazn... We can measure and improve the performance of our site for advertising purposes by these parties... Iyong Hand Sanitizer ba ay nasa listahan ng FDA ng mga produktong hindi dapat gamitin espaol ), in,. Within a topic to share pages and content that you find interesting on CDC.gov third! Hombres menores de 30 aos despus de la segunda dosis to confirm your preferences nm trong Danh sch cc phm! Assistance with reporting to VAERS, call 1-800-822-7967 inflamacin del corazn ( miocarditis... Privacy policy when you follow the link email systems use georgia.gov or ga.gov at end... 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In.gov parent, or legal representative before each dose of certain vaccines and therefore anonymous fix... 6 months of age and older as a primary series dng ca FDA khng this consent form, Spanish... 2 of 3 the vaccine may not protect everyone from COVID-19 disease to fix this.! Raro de inflamacin del corazn ( llamada miocarditis o pericarditis ) follow the..
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