State of Georgia government websites and email systems use georgia.gov or ga.gov at the end of the address. (Check back as we will continue to. CDC twenty four seven. Some page levels are currently hidden. Federal law requires that healthcare staff provide a VIS to a patient, parent, or legal representative before each dose of certain vaccines. 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@ . An official website of the United States government, : CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. V-Safe After Vaccination Health Checker - English PDF. Please remove any contact information or personal data from your feedback. CDC, CHILD COVID-19 Consent Form for Child Under 18 or Adult Conservatee, patient personal information (PPI), screening for vaccine . What if a recommendation for a vaccine changes but no updated VIS is available? 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. You will be subject to the destination website's privacy policy when you follow the link. %PDF-1.6 % Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Both forms must be complete at time of vaccination. Official Product Site; CDC: Pfizer-BioNTech COVID-19 Vaccine. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. Phone Number if different from above . Address if different from above . Thank you for taking the time to confirm your preferences. 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. 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. 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. ) or https:// means youve safely connected to the official website. %%EOF Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. A lock icon ( For further assistance with reporting to VAERS, call 1-800-822-7967. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM For COVID-19 Provider use only Clinic Name/Code: Location type: (clinic, health department, pharmacy, etc.,) . I understand that This product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA . 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. CDC twenty four seven. Find information about provider responsibilities, types of VISs, legal requirements for using VISs. <>/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 Pre-Vaccination Screening Form: English Spanish; Pfizer. Cookies used to make website functionality more relevant to you. Please limit your input to 500 characters. If you would like a response please use the enquiries form . Find VISs translated into other languages. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. Share sensitive information only on official, secure websites. 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. The Department of Health and Aged Care acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. endstream Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. This product (for ages 12 years and older) is no longer being distributed. Pfizer vaccine. . 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. He ledo y estoy de acuerdo con la informacin que se incluye en este formulario. There are different fact sheets for different age groups. Why are some dates on VISs so old? 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. Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. Cookies used to make website functionality more relevant to you. If you're having problems using a document with your accessibility tools, please contact us for help. 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'. Consent: I have the legal authority and have provided consent to the administration of the Pfizer-BioNTech COVID-19 Vaccine to \r\rCS321629E\rJanuary, 2023 197 0 obj <>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 (. secundarios leves despus de recibir una vacuna contra el COVID-19. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. An official website of the State of Georgia. Find answers to commonly asked questions. Cookies used to make website functionality more relevant to you. All information these cookies collect is aggregated and therefore anonymous. They help us to know which pages are the most and least popular and see how visitors move around the site. 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. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. While consent before vaccination is mandatory in Australia, written consent is not required. 404 0 obj You will be subject to the destination website's privacy policy when you follow the link. 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. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. 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 endobj CDC twenty four seven. hbbd```b``"H%dCh0MlT"A$^ 8H4hL F R- The recipients health condition or recommendations for vaccination may change from one visit to the next. When do we have to start using a new VIS? <>stream Thank you for your website feedback! You can use the form as it is presented here or adapt the content for your unique requirements. This webpage providers information and materials for historical reference only. Help us improve health.gov.au. I agree that: 1. We hope that you find these translations useful. Reporting is encouraged for other clinically significant adverse events, even if it is not clear that a vaccine caused the adverse event. 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. Individuals must complete a vaccine screening and consent form to confirm eligibility. Download a prevaccination checklist in multiple languages. Did You Know? CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. 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. New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes This consent form is not mandatory. (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). startxref Mass.gov is a registered service mark of the Commonwealth of Massachusetts. This product (for ages 12 years and older) is no longer being distributed. What are VISs? This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. 07/18/2022 Each VIS on this website is labeled with the date it was published. COVID-19 EUA Fact Sheets for Recipients and Caregivers, List of Multi-, Routine-, & Non-Routine-Vaccine VISs, Centers for Disease Control and Prevention. %%EOF The official version of thesetranslations is the English version. Please do not include personal or contact information. 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. We take your privacy seriously. ( 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 . 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. COVID-19; COVID-19 vaccines; Is there anything wrong with this page? The Moderna COVID-19 Vaccine is authorized in individuals 6 months of age and older as a primary series. (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. As a primary series any contact information or personal data from your feedback (... Types of VISs, legal requirements for using VISs about Pfizer-BioNTech COVID-19 Vaccines, Centers Disease! Updated VIS is available % EOF healthcare professionals are an essential and critical component to ensuring safe and vaccination... 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