More about Pfizer-BioNTech COVID-19 Vaccines Thank you for taking the time to confirm your preferences. 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. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. 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. You will be subject to the destination website's privacy policy when you follow the link. I agree that: 1. 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. There are different fact sheets for different age groups. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. endobj Cookies used to make website functionality more relevant to you. 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. Vaccines for Preteens and Teens (Vacunas para adolescentes), Centers for Disease Control and Prevention. 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. (FDA) ? Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 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 . Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. endobj Vaccine Information Statements (VISs) are information sheets produced by the CDC that explain both the benefits and risks of a vaccine to vaccine recipients. You can review and change the way we collect information below. Use this button to show and access all levels. This product (for ages 12 years and older) is no longer being distributed. We aim to provide documents in an accessible format. If you would like a response please use the enquiries form . Please let us know how we can improve this page. Share sensitive information only on official, secure websites. You will be subject to the destination website's privacy policy when you follow the link. They help us to know which pages are the most and least popular and see how visitors move around the site. La mayora de las personas que han tenido estas Please do not include personal or contact information. 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@ . 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 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. 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. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Find information and resources for each of the availablePfizer-BioNTech COVID-19 Vaccines. 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 understand that This product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA . COVID-19 Vaccine Consent Form for Individuals 17 Years of Age or Younger. Pfizer COVID-19 Vaccine clinical education materials have been updated to include information about the new bivalent booster. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. 07/18/2022 Pfizer's COVID-19 Vaccine Consent Form ( English / Spanish) Moderna's COVID-19 Vaccine Fact Sheet for Healthcare Providers Administering Vaccine . 2. endstream endobj startxref vacuna contra la COVID-19 de Pfizer o Moderna. (Materiales sobre la vacunacin en espaol). (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 (. 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. They help us to know which pages are the most and least popular and see how visitors move around the site. CDC twenty four seven. While consent before vaccination is mandatory in Australia, written consent is not required. Find VISs translated into other languages. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> A patient consent form for COVID-19 vaccination. The recipients health condition or recommendations for vaccination may change from one visit to the next. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Food and Drug Administration. 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 need to go back and make any changes, you can always do so by going to our Privacy Policy page. Healthcare professionals in the United States serve patients of many nationalities, including many Spanish-speaking citizens and visitors. Thank you for taking the time to confirm your preferences. 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. If you're having problems using a document with your accessibility tools, please contact us for help. We will use this information to improve this page. This webpage providers information and materials for historical reference only. CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages. 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. I reviewed this consent form and have read and understand the "Fact . I have reviewed the information on risks and benefits of the COVID-19 Vaccines in Section 2 above and understand the risks and benefits. Relacin con el menor. (Check back as we will continue to. (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). Thank you for your website feedback! %PDF-1.7 % Section 3: Consent. We are always looking for ways to improve our website. endstream 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. The .gov means its official.Federal government websites often end in .gov or .mil. Saving Lives, Protecting People, National Center for Immunization and Respiratory Diseases, Use of COVID-19 Vaccines in the U.S.: Appendices, FAQs for the Interim Clinical Considerations, Myocarditis and Pericarditis Considerations, Jurisdictions: Vaccinating Older Adults and People with Disabilities, Vaccination Sites: Vaccinating Older Adults and People with Disabilities, Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities, Vaccines for Children Program vs. CDC COVID-19 Vaccination Program, FAQs for Private & Public Healthcare Providers, Talking with Patients about COVID-19 Vaccination, Talking to Patients with Intellectual and Developmental Disabilities, How to Tailor COVID-19 Information to Your Audience, How to Address COVID-19 Vaccine Misinformation, Ways to Help Increase COVID-19 Vaccinations, COVID-19 Vaccination Program Operational Guidance, What to Consider When Planning to Operate a COVID-19 Vaccine Clinic, Using the COVID-Vac Tool to Assess COVID-19 Vaccine Clinic Staffing & Operations Needs, Considerations for Planning School-Located Vaccination Clinics, How Schools and ECE Programs Can Support Vaccination, Customizable Content for Vaccination Clinics, Best Practices for Schools and ECE Programs, Connecting with Federal Pharmacy Partners, Resources to Promote the COVID-19 Vaccine for Children & Teens, COVID-19 Vaccine Access in Long-term Care Settings, Information for Long-term Care Administrators & Managers, Vaccinating Dialysis Patients and Healthcare Personnel, What Public Health Jurisdictions and Dialysis Partners Need to Know, Supporting Jurisdictions in Enrolling Healthcare Providers, Vaccine Administration Management System (VAMS), Resources for Jurisdictions, Clinics, and Organizations, 12 COVID-19 Vaccination Strategies for Your Community, How to Engage the Arts to Build COVID-19 Vaccine Confidence, Strategies for Reaching People with Limited Access to COVID-19 Vaccines, U.S. Department of Health & Human Services. 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