Download and print these pieces or give your patients the Spanish-specific URLs and promote on-time vaccination across the life span in Spanish as well as in English. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. endobj A range of additional resources to support vaccination providers is available. These cookies may also be used for advertising purposes by these third parties. 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@ . CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. 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. endobj Complete and submit reports to VAERS online. All information these cookies collect is aggregated and therefore anonymous. endobj For health and safety reasons masks must be worn at all times during a vaccination event. The recipients health condition or recommendations for vaccination may change from one visit to the next. Bivalent vaccine (with a maroon vial cap and different label. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Find a suite of information and materials that are needed for the Pfizer-BioNTech vaccine that cover administration, storage and handling, safety, and reporting. 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 do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. vacuna contra la COVID-19 de Pfizer o Moderna. They help us to know which pages are the most and least popular and see how visitors move around the site. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. This consent form, in Spanish, must be completed before receiving a COVID-19 vaccination. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. If you are being inoculated by CVS, we've included that form below. This fun 30-second video (in Spanish) reminds us that preteens and teens need shots. (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 (. Before sharing sensitive information, make sure you're on a federal government site. If you need assistance, please contact the Department of Public Health. Please do not include personal or contact information. I acknowledge that I have had a chance to ask questions of a medical professional about the Pfizer Vaccine. para menores de 18 aos. Updated Smallpox/Monkeypox VIS Now Available, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services. Adverse events that occur in a recipient after COVID-19 vaccination are required to be reported to the Vaccine Adverse Event Reporting System (VAERS). If you need assistance, please contact the Department of Public Health. . CDC twenty four seven. 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. These cookies may also be used for advertising purposes by these third parties. 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. Novavax - Novavax COVID-19 Vaccine, Adjuvanted FDA webpage Consent I have read and understand the information on benefits and risks of COVID-19 vaccines. The .gov means its official.Federal government websites often end in .gov or .mil. Thank you for taking the time to confirm your preferences. . (Haga clic para ver este divertido video que nos recuerda que los preadolescentes y los adolescentes necesitan vacunarse.). 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. (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. endstream endobj startxref Please limit your input to 500 characters. ( 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 . Name (Last, First, Middle) Signature Date . Find answers to commonly asked questions. 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 . 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. . If my child or adult conservatee does not have a . You can review and change the way we collect information below. CDC twenty four seven. An official website of the State of Georgia. Why are some dates on VISs so old? endobj Thank you for taking the time to confirm your preferences. Food and Drug Administration. Please remove any contact information or personal data from your feedback. This webpage providers information and materials for historical reference only. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Vaccine information statements for Pfizer can be at www.cvdvaccine.com. endstream COVID-19; COVID-19 vaccines; Is there anything wrong with this page? Cookies used to make website functionality more relevant to you. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. 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. Your patients can download vaccine-specific, Spanish-language CDC podcasts to their computer and portable music/video player. V-Safe After Vaccination Health Checker - English PDF. %PDF-1.6 % English Espaol (Spanish) CDC COVID-19 Communication Toolkit: For Migrants, Refugees, and Other Limited-English-Proficient Populations in various languages Pfizer-BioNTech COVID-19. These cookies may also be used for advertising purposes by these third parties. Nc ra tay ca bn c nm trong Danh sch cc sn phm bn khng nn s dng ca FDA khng? New and Improved (Pneumococcal Conjugate) Vaccine (Una vacuna nueva y mejorada) 1:20 minutes Phone Number if different from above . You will be subject to the destination website's privacy policy when you follow the link. An official website of the State of Georgia. An official website of the United States government, : If you would like a response please use the enquiries form . It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. 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. Local, state, and federal government websites often end in .gov. We pay our respects to them and their cultures, and to elders both past and present. 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. Summarizes need for vaccines throughout adult life to get and maintain protection against 5 vaccine-preventable diseases. We are always looking for ways to improve our website. <>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> <>stream 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. 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