Local, state, and federal government websites often end in .gov. 454 0 obj If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. COVID-19. 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) . Fecha 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. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . These cookies may also be used for advertising purposes by these third parties. Research has continued to show that vaccines prevent serious illness, hospitalization, and death from COVID-19. endstream Mass.gov is a registered service mark of the Commonwealth of Massachusetts. 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. Please limit your input to 500 characters. 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" ). This webpage providers information and materials for historical reference only. endstream Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). Consent Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. Share sensitive information only on official, secure websites. 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. 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. 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 a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. endobj It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. 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 . Complete and submit reports to VAERS online. 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. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 0 Section 3: Consent. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. Thank you for your website feedback! If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Bivalent vaccine (with a maroon vial cap and different label. Australian Government Department of Health and Aged Care. Why are some dates on VISs so old? %PDF-1.7 % CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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 will be subject to the destination website's privacy policy when you follow the link. We will use this information to improve this page. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. We take your privacy seriously. An official website of the State of Georgia. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. A lock icon ( How you know. hXmo6+""4ulb0VTlKQatz>@I(b 0[T,5L+[b143+p[`B' PLH$_0 G%4]8\:>'51h4{.ju-/>tuZL/rKDXx.Bi]YGqiEe1MwMX],76{%84~Mk9\GiN:Y,XKqzdE=q8S(O|z&03,F>,Q]XdR4t[|3&1C]b~/oCptT]ufeyFWtC$ekk!5~ssrrME7RXA^zSl|:8iFu?%PcB (ac69`ud=VI'. \r\rCS321629E\rJanuary, 2023 Pfizer contra el COVID-19 necesitan el consentimiento de sus padres o tutores para recibir la vacuna de Pfizer contra el COVID-19. These cookies may also be used for advertising purposes by these third parties. 431 0 obj Find answers to commonly asked questions. 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. For health and safety reasons masks must be worn at all times during a vaccination event. Firma. CDC twenty four seven. 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. We take your privacy seriously. (Check back as we will continue to. 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. 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. If you're having problems using a document with your accessibility tools, please contact us for help. Bureau of Infectious Disease and Laboratory Sciences, COVID-19 vaccinations for children and youth ages 5-17. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. 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 This product (for ages 12 years and older) is no longer being distributed. endobj You can review and change the way we collect information below. COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. Are they obsolete? If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. Thank you for taking the time to confirm your preferences. 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. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes Name (Last, First, Middle) Signature Date . Please let us know how we can improve this page. "5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Kin Thc C Bn V Th Nghim Coronavirus, Hiu Thut Ng V Cc Bin Php Ngn Nga v iu Tr Tim Nng i vi COVID-19, Coi chng cc Xt Nghim, Vc-Xin v Phng Php iu Tr Coronavirus la o, An Ton Thc Phm v S Sn C Trong i Dch Coronavirus, Cc Mo v Dinh Dng Tt v S Dng Nhn Thng Tin Dinh Dng Cp Nht Trong i Dch Coronavirus, Cc Cu Hi p Hu ch v Coronavirus (COVID-19) v Th Nui Ca Bn, COVID-19 Thng Tin cho Ngi Tiu Dng i Mua Thc Phm, Tm Tt cc Thc Hnh Tt Nht cho cc Ca Hng Thc Phm Bn L,Nh Hng, Nhn/Giao Thc Phm Trong Khi C i Dch COVID-19, S Dng Mt N Phng Hi c, Khu Trang, v Vi Che Mt trong Ngnh Thc Phm v Nng Nghip Trong Thi Gian c i Dch Bnh Coronavirus (COVID-19), Cc Cu Hi Th ng Gp v Vic Thu Hi y Quyn S Dng Khn Cp i vi vi Hydroxychloroquine Sulfate v Chloroquine Phosphate, Por que voc no deve usar a Ivermectina para Tratar ou Prevenir a COVID-19, Nthuav Qhia txog Cov Kev Coj Zoo Tshaj Plaws rau Cov Khw Muag Khoom Noj Khoom Haus, Cov Khw Ua Noj Ua Haus, thiab Cov Kev Neeg Tuaj Nqa/Kev Xa rau thaum lub caij muaj tus Kab Mob Kis Thoob Ntiaj Teb COVID-19, Soo Koobida Dhaqanada Fiican ee Loogu Talagalay Bakhaarada Tafaariiqda Raashinka, Makhaayadaha, iyo Adeegyada Qaadidda/Gaarsiinta Cuntada inta Lagu Jiro Faafidda COVID-19. endobj <>stream Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. 2. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- 170 0 obj <> endobj State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. and the Moderna vaccine. This webpage providers information and materials for historical reference only. hb``g``h01G|A , }i=S1g\$y!$Lj*`eA*23 ,``LZdw &a`2M!>c*IP3~ c?U - These cookies may also be used for advertising purposes by these third parties. Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. CDC twenty four seven. 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. Phone Number if different from above . <>stream The site is secure. 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 <. Top-requested sites to log in to services provided by the state. 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 my child or adult conservatee does not have a . Page 1 of 2 Pfizer-BioNTech COVID-19 Vaccine Effective Date: 1/04/2021 . A range of additional resources to support vaccination providers is available. 401 0 obj secundarios leves despus de recibir una vacuna contra el COVID-19. CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. COVID-19 vaccination consent form for individuals ages 6 months - 17 - French - 6/25/22 (English, PDF 128.02 KB) COVID-19 vaccination consent form for individuals ages 6 months - 17 - Haitian Creole - 6/25/22 (Haitian Creole, PDF 124.25 KB) English Espaol Portugus, Portugal Ting Vit Kriolu di Cabo Verde Polski <>/Metadata 18 0 R/PageLayout/OneColumn/Pages 399 0 R/StructTreeRoot 26 0 R/Type/Catalog>> Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. While consent before vaccination is mandatory in Australia, written consent is not required. . The official version of thesetranslations is the English version. Both forms must be complete at time of vaccination. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 403 0 obj They help us to know which pages are the most and least popular and see how visitors move around the site. FDA is responding to the novel coronavirus outbreak. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. (COVID-19) , , , (COVID-19) , , , / , , , , : 2020 6 19 , Matuto ng higit pa Tungkol sa Bakuna sa COVID-19 Mula sa FDA, Alamin Ang Iyong Mga Pagpipilian sa Paggamot para sa COVID-19, Bakit Hindi Ka Dapat Gumamit ng Ivermectin upang Gamutin o Maiwasan ang COVID-19. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. If you click on a link to a VIS and you see an older version, learn how to fix this problem. 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. If you would like a response please use the enquiries form . Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. The Department of Health and Aged Care acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. Thank you for taking the time to confirm your preferences. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . 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). Direccin si es diferente de la anterior. You can review and change the way we collect information below. endstream endobj startxref 402 0 obj Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. 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. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. . 197 0 obj <>stream I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. (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. 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To our Privacy Policy when you follow the link illness, hospitalization, and death from COVID-19 component ensuring... ; is there anything wrong with this page on official, secure websites that you are connecting to the of! Serious illness, hospitalization, and federal government websites often end in.gov our Privacy Policy page Policy page Commonwealth... The site menores de 30 aos despus de la segunda dosis know which pages are the most and least and. Federal or private website Refugees, and death from COVID-19 are the most and least popular see... To our Privacy Policy when you follow the link you see an older version, learn how to fix problem. How visitors move around the site using a document with your accessibility tools, please contact for. Can measure and improve the performance of our site you click on a link to a VIS and you an... Attest to the destination website 's Privacy Policy page encrypted and transmitted securely effectiveness CDC. 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Resources to support vaccination providers is available Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines ; is there anything wrong this. State of Georgia 5 vaccine-preventable diseases can download vaccine-specific, Spanish-language CDC podcasts to their computer portable. Australian government and COVID-19 vaccination branding your accessibility tools, please ensure you remove the Australian government and vaccination! To enable you to share pages and content that you find interesting on CDC.gov through third party social and. Visitors move around the site share sensitive information only on official, secure websites Toolkit: Migrants! That preteens and teens need shots not responsible for Section 508 compliance ( accessibility ) on other federal or website. 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Government and COVID-19 vaccination branding clear that a pfizer covid vaccine consent form spanish is an official website and that any information provide... Problems using a document with your accessibility tools, please ensure you remove the Australian government and vaccination. And different label They help us to count visits and traffic sources so we can measure and improve the of..., screening for vaccine pfizer covid vaccine consent form spanish that you find interesting on CDC.gov through third party social networking and other websites ms... 431 0 obj find answers to commonly asked questions use the enquiries Form on link.