For health and safety reasons masks must be worn at all times during a vaccination event. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. CAIR Record web form. If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. A .mass.gov website belongs to an official government organization in Massachusetts. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to 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@ . 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. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. Share sensitive information only on official, secure websites. (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). 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Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. . Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? Thank you for taking the time to confirm your preferences. 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. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. 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 <. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. hbbd```b``V D}IN0Y 197 0 obj <>stream 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 If you are being inoculated by CVS, we've included that form below. What are VISs? (Una vacuna nueva y mejorada) 1:20 minutes, Recommended Immunizations for Children from Birth through 6 Years, Common Questions about Infant Vaccination, Tips for a Less Stressful Shot Visit [2 pages], How to Hold Your Child during Vaccinations, Meningococcal Vaccine for Preteens and Teens, Vaccines for Preteens and Teens: What Parents Should Know, Q&A for Parents of Preteens HPV Vaccine, Questions and Answers for Parents about Preteen Vaccines, Information for Parents about Preteen Vaccines, New and Improved (Pneumococcal Conjugate) Vaccine, National Center for Immunization and Respiratory Diseases, Myocarditis and Pericarditis Considerations, How to talk to your patients about COVID-19 vaccination, COVID-19 Vaccination Program Operational Guidance, U.S. Department of Health & Human Services. More about Pfizer-BioNTech COVID-19 Vaccines 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. 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. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. This webpage providers information and materials for historical reference only. They help us to know which pages are the most and least popular and see how visitors move around the site. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. <>stream All children 6 months to 17 years should . and the Moderna vaccine. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Local, state, and federal government websites often end in .gov. (Check back as we will continue to. If you click on a link to a VIS and you see an older version, learn how to fix this problem. Occupational Health and Safety Surveillance, Pregnancy Risk Assessment Monitoring System (PRAMS), Office of Health Indicators for Planning (OHIP), of Religious Objection to Immunization Spanish, Rules and Regulations: FAQs about Changes, Department of Public Health Certificate of Immunization (3231), Audit Checks for Child Care Facilities and Schools, Requirements and Recommendations for University System of Georgia Students, Guide 3231INS, Standards for Issuing and Filing Certificates of Immunization, of Georgia Immunization Requirements for Child Care & School Attendance, 3258 (Immunization Guidelines for Child Care Facility Operators and School Personnel), there for your child during shots (English and Spanish), for Teens: Protect Their Future (Spanish), Vaccine For Preteen Teaching Sheet English/, To the Wise: Immunize For Good Adult Health, of Refrigerated/Frozen Pack Needs for Different Climates, Recommendations Applying to Spacing and Administration of Routinely Recommended Childhood Vaccines, for Child and Adolescent Immunization Practices, Administration: Administer I.M. 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 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 We pay our respects to them and their cultures, and to elders both past and present. Please limit your input to 500 characters. 07/18/2022 Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Please let us know how we can improve this page. You will be subject to the destination website's privacy policy when you follow the link. 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 taking the time to confirm your preferences. endobj A range of additional resources to support vaccination providers is available. Immunize.org has organized links to all key printable (PDF) documents from CDC and FDA in the Checklist of Current Versions of U.S. COVID-19 Vaccination Guidance and Clinic Support Tools (abbreviated on this page as the "Checklist" ). Vaccine Storage, Handling, Preparation and Administration, Clinical Considerations and Recommendations, Georgia Requirements for School and Child Care Attendance, Childhood Immunization Requirements (For WIC and Clerical Personnel), Epidemiology and Prevention of Viral Hepatitis from A-E, Perinatal Hepatitis B- "A Pediatric Guide: Caring for Infants Exposed to Hepatitis B-Infected Mothers", Brochures/Teaching Sheets/Immunization Schedules. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. This consent form is not mandatory. CDC twenty four seven. . Pre-Vaccination Screening Form: English Spanish; Pfizer. English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. %PDF-1.7 % endstream If you need assistance, please contact the Department of Public Health. Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . 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. I reviewed this consent form and have read and understand the "Fact . Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. The Fact Sheet provides similar content to vaccine information statements (VISs) for licensed vaccines but differs in that the EUA Fact Sheet is specific to each authorized COVID-19 vaccine, is developed by the manufacturer of the vaccine, and is authorized by the FDA. Before administering vaccine, screen recipients for contraindications and precautions using the Prevaccination Checklist below, even if the recipient has received previous doses. I agree that: 1. Cookies used to make website functionality more relevant to you. V-Safe After Vaccination Health Checker - English PDF.
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