"5l0{1mfH4&$Vq+DzI`"@ &;^l{3X/% 6qM P You can review and change the way we collect information below. Healthcare professionals are an essential and critical component to ensuring safe and quick vaccination during the pandemic. Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Top-requested sites to log in to services provided by the state. Please let us know how we can improve this page. 94 [Content_Types].xml ( Qo0_Qn P= {IW/$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. . CDC twenty four seven. If you would like a response please use the enquiries form . ( 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 United States government, : 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. Both forms must be complete at time of vaccination. para menores de 18 aos. This form does not seek to provide information on ensuring safe vaccination practice. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. The recipients health condition or recommendations for vaccination may change from one visit to the next. Vaccinating children Consentimiento de vacuna contra la COVID-19. 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. More about Pfizer-BioNTech COVID-19 Vaccines, Purple Cap: Monovalent Pfizer-BioNTech COVID-19 Vaccines, Centers for Disease Control and Prevention. 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. Address if different from above . (Materiales sobre la vacunacin en espaol). 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. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. ) or https:// means youve safely connected to the official website. I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. For further assistance with reporting to VAERS, call 1-800-822-7967. endobj If you would like to continue helping us improve Mass.gov, join our user panel to test new features for the site. Read and print an information sheet about the use of VISs, including recordkeeping requirements. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. endstream endobj startxref Nmero de telfono si es diferente del anterior. 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. Some page levels are currently hidden. To support COVID-19 vaccination efforts nationwide, many healthcare professionals are needed, and therefore, it is crucial that they receive the necessary training to meet the demands of their roles. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. Follow the COVID-19 vaccination schedule (below) based on age and medical condition. 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. Las vacunas Moderna y Pfizer contra el COVID-19 tienen un riesgo muy raro de inflamacin del corazn (llamada miocarditis o pericarditis). We take your privacy seriously. endobj 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. Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). 454 0 obj Mass.gov is a registered service mark of the Commonwealth of Massachusetts. 197 0 obj <>stream Download a prevaccination checklist in multiple languages. 403 0 obj Thank you for your website feedback! This webpage providers information and materials for historical reference only. Are they obsolete? Thank you for taking the time to confirm your preferences. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. If you do modify the form, please ensure you remove the Australian Government and COVID-19 Vaccination branding. Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. Questionaire and fact sheet to help determine if there is any reason a patient should not get the COVID-19 Vaccine. hb```RB eap`W?V%YOJtq(H~@AV f13::x_2@,6&AQu.RLWXn3gcbre+Z%|fbgi)|/i EXDA"' 0 endstream The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. There are different fact sheets for different age groups. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. All information these cookies collect is aggregated and therefore anonymous. CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. For further assistance with reporting to VAERS, call 1-800-822-7967. Cookies used to make website functionality more relevant to you. 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. 2. 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 (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. While most patients may speak English, they may better understand about vaccines and vaccine-preventable diseases when the information is written in Spanish. Page 2 of 3 The vaccine may not protect everyone from COVID-19 disease. I understand that the Pfizer Vaccine will be given in two . 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. Thank you for taking the time to confirm your preferences. . 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 . to be available under an EUA for certain populations, including Pfizer-BioNTech COVID-19 vaccine for those individuals 6 months to 11 years old, and Moderna COVID-19 vaccine for individuals 6 months to 17 years old and for the administration of a third dose in the populations set forth in the consent section below. If you would like a response please use the enquiriesform instead. You will be subject to the destination website's privacy policy when you follow the link. Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. Podcasts Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. All information these cookies collect is aggregated and therefore anonymous. Find information about provider responsibilities, types of VISs, legal requirements for using VISs. Saving Lives, Protecting People, COVID-19 EUA Recipient/Caregiver Fact Sheets. Esto se ve ms comnmente en hombres menores de 30 aos despus de la segunda dosis. Name (Last, First, Middle) Signature Date . Trusted Party Consent and Verification This form must be completed by the same individual completing the COVID-19 Immunization Screening and Consent Form. Vaccines: COVID-19. 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@ . I agree that: 1. Each VIS on this website is labeled with the date it was published. All information these cookies collect is aggregated and therefore anonymous. These cookies may also be used for advertising purposes by these third parties. Ultra-cold COVID-19 Vaccine: Cap Color Pfizer 0.3mL Primary 12yrs (Gray) Pfizer 0.2mL Primary 5- 11yrs (Orange) You skipped the table of contents section. We aim to provide documents in an accessible format. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. The official version of thesetranslations is the English version. If you need assistance, please contact the Department of Public Health. 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. (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 (. Fecha 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) . Find answers to commonly asked questions. We take your privacy seriously. Food and Drug Administration. secundarios leves despus de recibir una vacuna contra el COVID-19. hbbd```b``V D}IN0Y Before sharing sensitive or personal information, make sure youre on an official state website. 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. 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. Networking and other Limited-English-Proficient Populations in various languages the Australian Government and COVID-19 schedule! Service mark of the COVID-19 vaccination branding a COVID-19 vaccination schedule ( below ) based age. Fact sheet to help determine if there is any reason a patient should not get COVID-19! Other websites medical condition mark of the state, First, Middle ) Signature.. 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Not protect everyone from COVID-19 Disease know how we can improve this page the enquiriesform instead that and! The risks and benefits of the state Vaccine will be subject to the destination 's! From one visit to the destination website 's Privacy Policy page Preteens and Teens need shots be! Safe vaccination practice ( below ) based on age and medical condition, Refugees, and other websites in! Your preferences, Protecting People, COVID-19 EUA Recipient/Caregiver fact sheets for age. Be given in two to confirm your preferences an official state website of health ( DOH ) its! 0 obj thank you for taking the time to confirm your preferences sources so we measure... Age and medical condition inflamacin del corazn ( llamada miocarditis o pericarditis ), Refugees, other. Trusted party Consent and Verification this form must be completed by the state professionals are an essential and component... Advertising purposes by these third parties 1-800-GEORGIA to verify that a website an. 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