COVID Page 1 of 2 OPH Form _____; Rev. I have been provided with the opportunity to read the COVID-19Vaccine Fact Sheet forRecipients and understand potentialhealth risks and warningsymptoms. Province of Manitoba COVID Janssen COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers - (Khmer) PDF. Page 2 of 2 I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet or Vaccine Information Statement (VIS-if available), a copy of which I was provided with this Consent Form. f vaccine received. Some documents are presented in Portable Document Format (PDF). Informed Consent: I answered all the questions correctly to the best of my knowledge. Patient Information . Get Vaccinated! By signing this form, I certify that I have the legal Required Forms Prior to Vaccination. For COVID-19 shots, the majority of the states require parental consent for minors. 2. I GIVE CONSENT for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech COVID-19 Vaccine and have reviewed and agree to the information included in this form. The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. For vaccine recipients: The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. COVID-19 Vaccination Consent Form Last Name (Please print) First Name MI Date of Birth Male Female Other Address City State Zip Phone Number Email Name of Primary Care Provider SCREENING FOR VACCINATION ELIGIBILITY 1. COVID-19 Immunization Screening and Consent Form; The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. I consent to inclusion of this immunization data in the Kansas Immunization Information System (KSWebIZ) for myself. PHE_Covid-19_consent_form_adults_able_to_consent_v2 Author: Public Health England Subject: COVID-19 vaccination Keywords; COVID-19 vaccination adult consent form; Public Health England gateway number 2020376; Product code: COV2020376 V2 Created Date: 20210120184510Z Screening Questionnaire and Consent Form vaccine(s). A consent form is a signed document that outlines the informed consent of an individual for a medical study, clinical trial, or activity. COVID-19 vaccination consent form for frontline social care workers (PDF version) Ref: PHE gateway number 2020408 PDF , 51.7KB , 1 page This COVID-19 Vaccine Consent Form WHAT TO DO IF YOU HAVE A REACTION TO THE COVID-19 VACCINATION Most people have side effects from the vaccination, but these usually only last 24 48 hours after receipt of the vaccination. Attachment D, Page 1 Dangers & Toxicities (This is a section of the vaccine package insert from Pfizer-BioNTech Covid-19 vaccine.There are known risks, as well as unknown risks with this vaccine. Consent to Receive the Vaccine I have read (or it has been read to me) and I understand the Immunization Prepackage, including the following documents: COVID-19 Vaccine Information Sheet or the COVID-19 Vaccine Information Sheet: For Children (age 5-11) and What you need to know about your Covid-19 vaccine appointment. Consent to Receive the Vaccine I have read (or it has been read to me) and I understand the Immunization Prepackage, including the following documents: COVID-19 Vaccine Information Sheet or the COVID-19 Vaccine Information Sheet: For Children (age 5-11) and What you need to know about your Covid-19 vaccine appointment. covid-19 immunization consent form pha000157 1220 date of vaccination/date vis given pharmacist/prescriber signature pharmacy name pharmacy address This consent form is not mandatory. Page 2 of 2. Further, I understand that a booster dose of COVID-19 vaccine may be recommended at least 2 months following the first dose of Janssen vaccine or at least 6 months following the second dose of Pfizer-BioNTech or Moderna COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, 18 years old or older and a resident of Janssen COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers - English PDF. I ask that the vaccine be administered to me. Options for Consent. NSP Vaccine Administration Consent Form- Rev.
The vaccine for children in this age group is a smaller dose (one-third) This is important because COVID-19 can cause severe sickness or death. A PDF reader is required for viewing. o Previous dose of COVID -19 vaccine 3) Have you ever had an .

Persons younger than 18 years must have parental or guardian consent given by a If you need help, please ask a staff person. Have you previously received any other Covid vaccines? 10/21 SECTION D: ATTESTATION AND CONSENT.. Download the agreement. While consent before vaccination is mandatory in Australia, written consent is not required. X . COVID-19 Vaccination Consent Form Author: Public Health England Subject: COVID-19 Vaccination Consent Form. EUAs for COVID-19 Vaccine in Other Languages; (Signature of patient or parent/guardian). The COVID-19 vaccine planning efforts will be based on three phases of availability; potentially limited doses available, Whether youre looking for a way to gather model releases, activity waivers, parental consent, or medical consent forms, you can start by selecting one of Complete ONLY ONE of the following two options: 1.Consent by legal decision maker I consent to the above named person receiving the COVID-19 vaccine. The COVID-19 vaccine protects your child from getting sick from the virus that causes COVID-19. Food and Drug Administration. Moderna COVID-19 vaccine www.modernatx.com. COVID VACCINE: Vaccine records reviewed (Partner initials):_____ Dose # Provided (circle): 1 2 3 _____ Inactivated Influenza Fluzone HD 0.7 ml Sanofi Pasteur IM RD LD Inactivated Influenza Flublok 0.5 ml Sanofi Pasteur IM RD LD Inactivated Influenza Fluad 0.5 ml Seqirus IM RD LD The Janssen COVID-19 Vaccine is an unapproved vaccine. Page 2 of 2 DOH COVID-19 Vaccination Consent Form Effective Date: 11/04/2021 DH8010-DCHP-08/2021 Icertify thatam: (a) the patientand at least18 years ofage; (b) legal guardian confirm is 5 age (for Pfizer vaccine consent only); or (c) legally authorized to consent for Patient has no visible or declared symptoms of COVID-19 Patient has documentation of next dose schedule: (mm/dd/yyyy) Vaccinating Pharmacist/HCP Name This includes all students aged 12 and over. COVID Vaccine Intake Consent Form Clinic Information . The UKMFA have produced a referenced consent form for use by doctors and their patients to aid the process of obtaining full informed consent before having a COVID-19 vaccine. I have read, had explained to me, and understand the information in the EUA.

If a parent or guardian cannot be at the appointment, they can give consent in writing using the consent form at ahs.ca/VaccineUnder18. least 16 years of age; or (c) authorized to consent for vaccination for the patient named above. Clinic ID Clinic Name Telephone Store Number Address City State Zip. 2.Can you please provide a copy of the informed consent form to be given to recipients of COVID-19/SARS/CoV-2 vaccines in New Zealand. When a prescription is used, the prescriber must retain this form or a copy, and hold securely as a medical record COVID-19 Vaccine Consent Form . Children 5-11 years of age need a different formulation of the Pfizer vaccine which contains a smaller dose (1/3 rd the dose that teens and adults receive).. Search below by age or vaccine type to find a location that has the right Pfizer vaccine for your child. I consent to, or give consent for, the administration of the vaccine(s) marked below by a Hannaford pharmacist.

COVID-19 Vaccine Consent Form . By signing this form, I would like the COVID-19 vaccine given to myself. I understand that the COVID-19 vaccine is a voluntary vaccine currently being given under the Emergency Use Authorization status and only a parent or legal guardian has the authority to consent to a minor or adult conservatee receiving this vaccine. 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 Your child cannot get COVID-19 from the vaccine. V e r s i o n 3 . Do you currently or have you in the past 14 days had a fever, cough, shortness of breath, or loss of sense of taste and smell 4. Sheet for the vaccines indicated on this form. Please answer the questions belowto help us determine if there is any reason you should not get the COVID-19 vaccine today. Last Name First Name Identification (e.g., health card number) Gender: Female Male Prefer not to answer Other: _____ Primary Care Clinician (Family Physician or Nurse Practitioner) I consent to receive the vaccine provided. 5. I have reviewed my specific vaccine EUA Fact Sheet or have had its contents including the benefits, the usual and A few people may have no side effects at all. The COVID-19 vaccine initially will be available in very limited doses but will scale up in production rapidly allowing for enough supply to vaccinate all. NOTE: Depending on vaccine type, a second dose of COVID-19 vaccine may be due in 21 days or 28 days after initial vaccine. Also, some state legislators have introduced bills specifically addressing the COVID-19 vaccine for minors.

COVID-19 Testing Consent Form This form is required for employees who declined to certify their vaccination status on the COVID-19 Attestation Form, requiring them to be tested for COVID-19 weekly in accordance with the State policy. This form is used to determine if the COVID-19 vaccine can be administered to the pediatric patient. Y / N 2. About COVID-19 vaccination People who have a COVID-19 vaccination have a much lower chance of getting sick from Consent I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. section 1: information about you (please print) last name utsa id (abc123) For COVID-19 Vaccine: I have been provided and have read, or had explained to me, the patient fact sheet corresponding to the COVID-19 vaccination given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). Do NOT discard it as you will need that same code for your second dose appointment. Consent form for COVID-19 vaccination Before completing this form, make sure you have read the information sheet on the vaccine you will be receiving, either COVID-19 Vaccine AstraZeneca or Comirnaty (Pfizer).

If you receive COVID-19 Registration Code, be sure to bring that with you to your appointment. Covid-19 Vaccine Consent Form Pfizer Moderna Janssen Dose 1 Dose 2 Dose 3 Date Given Lot/Exp Date Deltoid Location Route Immunizer Signature VIS Date R / L IM 1. In clinical s, more than 61,000trial individuals 18 years of age and older have received the Janssen COVID-19 Vaccine. I understand the FDA has authorized emergency use of the COVID-19 vaccine, which is not an FDA-approved vaccine. CONSENT FORM COVID-19 Vaccine . Immunization Consent Form PHA000021B 0217 A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. Pfizer-BioNTech COVID-19 Vaccine Consent Form for Individuals Under 18 Years of Age. In some cases, children under age 18 years may Download Vaccine Administration Record (VAR)Informed Consent for Vaccination (PDF) PRINT NAME _____ DOB _CELL NUMBER_____ DEPARTMENT/SPECIALTY TITLE_____ NAME OF EMPLOYER (For contractors) _____ Phone number_____ PLEASE CHECK ANY THAT APPLY AND NOTIFY THE NURSE PRIOR TO ADMINISTRATION If you answer yes to any of the questions, you should discuss with your physician before receiving the vaccine. While H-E-B reserves the right to not do so, I consent to H-E-B reporting my immunization information to the State Immunization Registry. COVID-19 Vaccine Consent Form (Fillable) (legal size) (Updated October 2021) COVID-19 Vaccine Consent Form (Print) (legal size) (Updated October 2021) Everyone who is immunized must complete this consent form. DOH COVID-19 Vaccination Consent Form to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. Patient Information (Staff only) Appointment ID: Last Name First Name Middle Name (optional) Mothers Maiden Name (Optional) Date of Birth (MM/DD/YYYY) Gender Address No address available Insurance Information Parents/guardians can also use it to provide proof of a student's in-process vaccination plan. MEDICAL HISTORY: Complete the following questions for individual receiving vaccine.

Have you received another vaccine in the last 14 days? Please provide a copy of this form to your physician and/or healthcare provider for your permanent medical records. I understand that if this vaccine requires two doses, two doses of this vaccine will need to be administered (given)in order for it to be effective. PARENTS PLEASE COMPLETE THE SCREENING QUESTIONNAIRE ON BACK ***** CHS-2b_COVID_sch rev. More information on the risks and benefits of the Pfizer vaccine can be found on the Pfizer COVID-19 Vaccine Benefits and Risks Fact Sheet (PDF). If there is a potential of risk, there must be a Most COVID-19 vaccines require two doses 21-28 days apart for optimal efficacy. The risk of any vaccine causing serious harm, or death, is extremely small. 1.5 School based vaccination providers will adhere to Ministry of Education informed consent policy when administering the vaccine, in that written consent is obtained from a parent or guardian prior to vaccine administration and the details recorded in the COVID Immunisation Register (CIR). I GIVE CONSENT. Signature of Patient Date School and child care professionals can use this form to notify parents/guardians of immunization requirements. It is provided as an example for vaccination providers to obtain patient consent prior to COVID-19 vaccination. I consent to, or give consent for, the administration of the vaccine(s). Page 1 of 2 Moderna COVID-19 Vaccine Effective Date: 12/21/2020 COVID-19 VACCINE SCREENING AND CONSENT FORM Moderna COVID-19 Vaccine SECTION 1: INFORMATION ABOUT YOU (PLEASE PRINT) Name: Last: First: Middle Initial: Date of Birth: Month Day Year Mobile Phone Number (Patient or Version 4.0 August 17, 2021 . AstraZeneca as the secondary dose of the primary course (ie following non-AstraZeneca COVID-19 vaccine for dose 1), this should be signed below by the clinical lead. I for 12 15 year olds. I have been given a copy and have read, or have had explained to me, the information in the FACT SHEET for the COVID-19 vaccine. VACCINATION CONSENT FORM . Pfizer vaccine consent only); or (c) legally authorized to consent for vaccination for the patient named above. Unfortunately, different brands of COVID-19 vaccine CANNOT be mixed. Choose a location that offers Pfizer vaccine.. Pfizer is the only vaccine that can be given to people under the age of 18. Pfizer COVID-19 Consent 04.2021v1 I certify that I am: (a) the parent or legal guardian of the patient and confirm that the patient is at least 16 years of age; or (b) authorized to consent for vaccination for the patient named above. COVID-19 Vaccination Consent Form. COVID-19 Vaccine Screening and Consent Form . Most people will experience pain, redness and/or soreness at the injection site. Once you have submitted your information, a PDF of the contract will download automatically. I have had the opportunity to ask questions about the vaccine(s) which were answered to my satisfaction. Certificate of Immunization for college/university students; Vaccine exemptions Notice of Immunization Requirement and In-Process Form. My consent applies to all doses of the vaccine necessary to complete the series up to one year. 3.Can you please provide instructions to vaccinators administering COVID- 0 1 9 th N o v e m b e r 2 0 2 1 I h a ve re a d a n d u n d e rst a n d t h e va cci n e i n f o rma t i o n i n cl u d i n g t h e kn o w n si d e e f f e ct s Signature of Legally Authorized Representative. I have been offered a copy of the COVID-19 Emergency Use Authorization (EUA). Children under age 18 years need a parent or guardian to give consent for them to get a COVID-19 vaccine. COVID Vaccine Intake Consent Form. It just means additional questions may be asked. Patient, Parent/Legal Guardian, Person Acting in Loco Parentis-Printed Name Signature Date . Page 1 of 2 FCHC COVID-19 Vaccination Consent Form Effective Date: 9/17/2021 DH8010-DCHP-08/2021 . Have you had a seizure or a brain or other nervous system problem or Guillain Barre? This form will provide your institution with confirmation of your consent to be tested. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers - English PDF. The exceptions are Arkansas, Washington, D.C., Idaho, Oregon, Rhode Island, South Carolina, Tennessee and Washington. Therefore, to receive the first shot of one brand of vaccine requires that a vaccinee be able to receive the same brand about 21-28 days later. for the child named at the top of this form to get vaccinated with the Pfizer-BioNTech COVID-19 Date. It just means additional questions may be the costs of administering the vaccine. ADHS COVID-19 Vaccine Consent Form Use this form in conjunction with the CDC Pre-Vaccination Checklist for COVID-19 Vaccines. CONSENT 1. PROVIDER COVID-19 IMMUNIZATION CONSENT FORM 1. If you answer yes to any question, it does not necessarily mean you should not be vaccinated. allergic reaction. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any vaccine or If a question is not clear, please ask your healthcare provider to explain it. I give consent to the Health Department and its authorized staff for my child named at the top of this form to receive the COVID-19 vaccine. Scenario 2: Full Approval. 5. I fully release and discharge Rite Aid Corporation, its affiliates, officers, directors, and employees from any liability for illness, injury, loss, or damage I certify that I am: (i) the Patient and at least 18 years of age; (ii) the patients personal representative. If you answer YES you may not be able to receive the COVID-19 vaccine. Name of Parent or Legal Guardian (Last, First, Middle) Signature Date Address if different from above Janssen (J&J) Janssen COVID-19 Vaccine EUA Fact Sheet for Providers; Janssen COVID-19 Vaccine EUA for Recipients and Caregivers; VSAFE; Example of Consent Form; Other Language Resources and Forms. covid-19 (01/2021) covid-19 vaccine screening and consent form pfizer-biontech covid-19 vaccine . The minimum waiting period between vaccines is 14 days. Vaccine Administration Record (VAR)Informed Consent for Vaccination For COVID-19 vaccine only: Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies Yes or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent form. Page 1 of 2 DOH COVID-19 Vaccination Consent Form Effective Date: 1/25/2021 DH8010-DCHP-01/2021 COVID-19 VACCINE SCREENING AND CONSENT FORM SECTION 1: INFORMATION ABOUT PATIENT (PLEASE PRINT) Name: Last: First: Middle Initial: Further, I hereby give my consent to the Howard County Health Department (HCHD) to administer the COVID-19 vaccine. Further, I hereby give my consent to the Florida Department of Health (DOH) or Last updated: 22 July 2021 . Y o u n g P e r s o n ' s N a m e : 3. 2019(COVID-19).Like all medicines,o vaccine is completely effective and it takes a few weeks after the vaccine for the body to build up protection.Some people maytill geCOVID-19espite having a vaccination,ut this should lessen the severityf any infection.The vaccine cannot give a persoCOVID-19isease, Before Covid-19, workplace vaccine mandates for adults were on a state-by-state basis and primarily focused on hepatitis B and influenza vaccination in health care settings, often allowing some accommodation for disability or religious beliefs. that a COVID-19 vaccine may help keep me from becoming seriously ill, even if I do become infected with COVID-19. In partnership with the Citys vaccination effort, some school sites are offering the first dose of Pfizer vaccinations to eligible students ages 5-11 during the month of November. A parent or guardian should complete the consent form for youths under 18. If YES refer to Pfizer website at www.PfizerMedInfo.com. Example of Consent Form; Moderna. Y / N 3.
(live or non-live). I have had the chance to ask questions that were answered to my satisfaction. Public Health Seattle & King County COVID-19 Vaccine Minor Consent Form (PDF) This form is used at Public Health Seattle & King County vaccination sites, including the Auburn and Kent Vaccination Partnership Sites and Public Health clinics. Vaccine Informed Consent Form . The vaccine does not contain a live virus. Information collected on this form will be used to document authorization for receipt of vaccine(s). IHca[Ith nnn SECTION 3: IMMUNIZATION SCREENING GUIDANCE FOR COVID-19 VACCINE Please check YES or No for each question. of COVID-19/SARS/CoV-2 vaccines so that they can make an informed choice before deciding whether to have the vaccine or not. If your student is aged 5-11, they can now receive a free COVID-19 vaccine at school! To access the COVID-19 Vaccine Agreement, simply fill out the form below and click the download button. COVID-19 Screening Questions (continued) Yes No Dont Know 3. Further, I hereby give my consent to the Florida Department of Health (DOH) or its agents to administer the COVID-19 vaccine. If applicable, I give Big Y Pharmacy Refer Refer to your COVID-19 5/11/2021 Pfizer-BioNTech COVID-19 Vaccine Consent and Screening Form for Individuals Under 18 Years of Age Section 1: Information About Section 3 Consent For all doses of the COVID-19 vaccine, your consent will confirm the following: I have read the information I was given on the COVID-19 vaccine being offered to me today and consent to have administered the two required doses, and an Patient Signature: _____ Date: _____

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