HomeMy WebLinkAbout09.27.21 COVID-19 vaccine consent form and information
From:York, Danette
To:Alpert, Bruce;Bennett, Robin;Clerk of the Board;Connelly, Bill;Cook, Holly;Cook, Robin;Hironimus, Patrizia;
Kimmelshue, Tod;Lucero, Debra;Paulsen, Shaina;Pickett, Andy;Reaster, Kayla;Ring, Brian;Ritter, Tami;
Sweeney, Kathleen;Teeter, Doug
Cc:Kim, Sang
Subject:COVID-19 vaccine consent form and information
Date:Monday, September 27, 2021 2:32:40 PM
Attachments:Pfizer-BioNTechCOVID-19VaccineMinorConsentForm-English.pdf
MyTurn-RegistrationForm.pdf
MyTurn-ScreeningQuestionsandVerbalConsent14Languages.pdf
EUA 20734_VI FS for Recipients_Pfizer-BioNTech COVID-19 Vaccine_FINAL_22Sep2021.pdf
How to Replace Your COVID.docx
Just as an FYI in case you need this information in response to questions about informed consent for
COVID-19 vaccine. Attached and in links below are documents people get and see prior to getting a
COVID-19 vaccine.
Respectfully,
Danette York
Public Health Director
BUTTE COUNTY PUBLIC HEALTH
202 Mira Loma Drive | Oroville, CA 95965
T:530.552.3820 | F: 530.538.2164
COVID-19 Call Center: 530.552.3050 Open 8 am-5 pm, everyday
FACEBOOK | TWITTER
COUNTY OF BUTTE E-MAIL DISCLAIMER: This e-mail and any attachment thereto may contain private, confidential, and privileged
material for the sole use of the intended recipient. Any review, copying, or distribution of this e-mail (or any attachments thereto) by
other than the County of Butte or the intended recipient is strictly prohibited. If you are NOT the intended recipient, please contact the
sender immediately and permanently delete the original and any copies of this e-mail and any attachments thereto.
From: Bonnifet, Kristy <KBonnifet@buttecounty.net>
Sent: Monday, September 27, 2021 9:02 AM
To: York, Danette <DYork@buttecounty.net>
Cc: Cox, Erin <ECox@buttecounty.net>; Bhakta, Krishan <KBhakta@buttecounty.net>
Subject: COVID-19 vaccine consent form
Hi Danette,
These attachments and the links below should comprise all the forms that patients see when
they register and then present at the clinic. There are questionnaires from My Turn, minor
consent forms, the EUA fact sheets and info on how to get a new CDC card if needed.
EUA PDF Links:
-Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Healthcare Providers Administering
Vaccine (Vaccination Providers) (fda.gov)
-Moderna COVID-19 Vaccine Fact Sheet for Health Care Providers (fda.gov)
-Janssen COVID-19 Vaccine Fact Sheet for Recipients and Caregivers (fda.gov)
Please let us know if you have questions.
Thanks!
202 Mira Loma Drive | Oroville, CA 95965
T:530.552.3999 | F: 530.538.2165
COVID-19 Call Center: 530.552.3050 Open 8 am-4:30 pm, everyday
FACEBOOK | TWITTER
COUNTY OF BUTTE E-MAIL DISCLAIMER: This e-mail and any attachment thereto may contain private, confidential, and privileged
material for the sole use of the intended recipient. Any review, copying, or distribution of this e-mail (or any attachments thereto) by
other than the County of Butte or the intended recipient is strictly prohibited. If you are NOT the intended recipient, please contact the
sender immediately and permanently delete the original and any copies of this e-mail and any attachments thereto.
VACCINE INFORMATION FACT SHEET FOR RECIPIENTS AND CAREGIVERS
ABOUT COMIRNATY (COVID-19 VACCINE, mRNA)
AND PFIZER-BIONTECH COVID-19 VACCINE TO PREVENT CORONAVIRUS
DISEASE 2019 (COVID-19)
You are being offered either COMIRNATY (COVID-19 Vaccine, mRNA) or the
Pfizer-BioNTech COVID-19 Vaccine to prevent Coronavirus Disease 2019
(COVID-19) caused by SARS-CoV-2.
This Vaccine Information Fact Sheet for Recipients and Caregivers comprises the
Fact Sheet for the authorized Pfizer-BioNTech COVID-19 Vaccine and also
includes information about the FDA-licensed vaccine, COMIRNATY (COVID-19
Vaccine, mRNA).
The FDA-approved COMIRNATY (COVID-19 Vaccine, mRNA) and the
FDA-authorized Pfizer-BioNTech COVID-19 Vaccine under Emergency Use
Authorization (EUA) have the same formulation and can be used interchangeably
\[1\]
to provide the COVID-19 vaccination series.
COMIRNATY (COVID-19 Vaccine, mRNA) is an FDA-approved COVID-19
vaccine made by Pfizer for BioNTech. It is approved as a 2-dose series for
prevention of COVID-19 in individuals 16 years of age and older. It is also
authorized under EUA to provide:
a two-dose primary series in individuals 12 through 15 years;
a third primary series dose in individuals 12 years of age and older who
have been determined to have certain kinds of immunocompromise;
and
a single booster dose in individuals:
o 65 years of age and older
o 18 through 64 years of age at high risk of severe COVID-19
o 18 through 64 years of age whose frequent institutional or
occupational exposure to SARS-CoV-2 puts them at high risk of
serious complications of COVID-19 including severe COVID-19
The Pfizer-BioNTech COVID-19 Vaccine has received EUA from FDA to
provide:
a two-dose primary series in individuals 12 years of age and older;
a third primary series dose for individuals 12 years of age and older
who have been determined to have certain kinds of
immunocompromise; and
a single booster dose in individuals:
o 65 years of age and older
\[1\]
The licensed vaccine has the same formulation as the EUA-authorized vaccine and the products can
be used interchangeably to provide the vaccination series without presenting any safety or effectiveness
concerns. The products are legally distinct with certain differences that do not impact safety or
effectiveness.
1 Revised: 22 September 2021
o 18 through 64 years of age at high risk of severe COVID-19
o 18 through 64 years of age whose frequent institutional or
occupational exposure to SARS-CoV-2 puts them at high risk of
serious complications of COVID-19 including severe COVID-19
This Vaccine Information Fact Sheet contains information to help you understand the
risks and benefits of COMIRNATY (COVID-19 Vaccine, mRNA) and the
Pfizer-BioNTech COVID-19 Vaccine, which you may receive because there is currently
a pandemic of COVID-19.Talk to your vaccination provider if you have questions.
This Fact Sheet may have been updated. For the most recent Fact Sheet, please see
www.cvdvaccine.com.
WHAT YOU NEED TO KNOW BEFORE YOU GET THIS VACCINE
WHAT IS COVID-19?
COVID-19 disease is caused by a coronavirus called SARS-CoV-2. You can get
COVID-19 through contact with another person who has the virus. It is predominantly a
respiratory illness that can affect other organs. People with COVID-19 have had a wide
range of symptoms reported, ranging from mild symptoms to severe illness leading to
death. Symptoms may appear 2 to 14 days after exposure to the virus. Symptoms may
include: fever or chills; cough; shortness of breath; fatigue; muscle or body aches;
headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or
vomiting; diarrhea.
WHAT IS COMIRNATY (COVID-19 VACCINE, mRNA) AND HOW IS IT RELATED TO
THE PFIZER-BIONTECH COVID-19 VACCINE?
COMIRNATY (COVID-19 Vaccine, mRNA) and the Pfizer-BioNTech COVID-19 Vaccine
have the same formulation and can be used interchangeably to provide the COVID-19
1
vaccination series.
For more information on EUA, see the “What is an Emergency Use Authorization
(EUA)?” section at the end of this Fact Sheet.
WHAT SHOULD YOU MENTION TO YOUR VACCINATION PROVIDER BEFORE
YOU GET THE VACCINE?
Tell the vaccination provider about all of your medical conditions, including if
you:
have any allergies
have had myocarditis (inflammation of the heart muscle) or pericarditis
(inflammation of the lining outside the heart)
have a fever
1
The licensed vaccine has the same formulation as the EUA-authorized vaccine and the products can be
used interchangeably to provide the vaccination series without presenting any safety or effectiveness
concerns. The products are legally distinct with certain differences that do not impact safety or
effectiveness.
2 Revised: 22 September 2021
have a bleeding disorder or are on a blood thinner
are immunocompromisedor are on a medicine that affects your immune system
are pregnant or plan tobecome pregnant
are breastfeeding
have received another COVID-19 vaccine
have ever fainted in association with an injection
HOW IS THE VACCINE GIVEN?
Thevaccine will be given to you as an injection into the muscle.
Primary Series: The vaccine isadministered as a 2-dose series, 3 weeks apart.Athird
dose may be administered at least 4 weeks after the second dose to individuals who
are determined to have certain kinds of immunocompromise.
Booster Dose: A single booster dose of the vaccine may be administered to individuals:
65 years of age and older
18 through 64 years of age at high risk of severe COVID-19
18 through 64 years of age whose frequent institutional or occupational exposure
to SARS-CoV-2 puts them at high risk of serious complications of COVID-19
including severe COVID-19
The vaccine may not protect everyone.
WHO SHOULD NOTGET THE VACCINE?
You should not get the vaccine if you:
had a severe allergic reaction after a previous dose of this vaccine
had a severe allergic reaction to any ingredient of this vaccine.
WHAT ARE THE INGREDIENTS IN THE VACCINE?
The vaccine includes the following ingredients: mRNA, lipids ((4-
hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate), 2 \[(polyethylene
glycol)-2000\]-N,N-ditetradecylacetamide, 1,2-Distearoyl-sn-glycero-3-phosphocholine,
and cholesterol), potassium chloride, monobasic potassium phosphate, sodium
chloride, dibasic sodium phosphate dihydrate, and sucrose.
HAS THE VACCINE BEEN USED BEFORE?
Yes. In clinical trials, approximately 23,000 individuals 12 years of age and older have
received at least 1 dose of the vaccine. Data from these clinical trials supported the
Emergency Use Authorization of the Pfizer-BioNTech COVID-19 Vaccine and the
approval of COMIRNATY (COVID-19 Vaccine, mRNA). Millions of individuals have
received the vaccine under EUA since December 11, 2020.
3 Revised: 22 September 2021
WHAT ARE THE BENEFITS OF THE VACCINE?
The vaccine has been shown to prevent COVID-19.
The duration of protection against COVID-19 is currently unknown.
WHAT ARE THE RISKS OF THE VACCINE?
There is a remote chance that the vaccine could cause a severe allergic reaction. A
severe allergic reaction would usually occur within a few minutes to one hour after
getting a dose of the vaccine. For this reason, your vaccination provider may ask you to
stay at the place where you received your vaccine for monitoring after vaccination.
Signs of a severe allergic reaction can include:
Difficulty breathing
Swelling of your face and throat
A fast heartbeat
A bad rash all over your body
Dizziness and weakness
Myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the
lining outside the heart) have occurred in some people who have received thevaccine.
In most of these people, symptoms began within a few days following receipt of the
second dose of vaccine. The chance of having this occur is very low. You should seek
medical attention right away if you have any of the following symptoms after receiving
the vaccine:
Chest pain
Shortness of breath
Feelings of having a fast-beating, fluttering, or pounding heart
Side effects that have been reported with the vaccine include:
severe allergic reactions
non-severe allergic reactions such as rash, itching, hives, or swelling of the face
myocarditis (inflammation of the heart muscle)
pericarditis (inflammation of the lining outside the heart)
injection site pain
tiredness
headache
muscle pain
chills
joint pain
fever
injection site swelling
injection site redness
nausea
feeling unwell
swollen lymph nodes (lymphadenopathy)
decreased appetite
diarrhea
4 Revised: 22 September 2021
vomiting
arm pain
fainting in association with injection of the vaccine
These may not be all the possible side effects ofthe vaccine. Serious and unexpected
side effects may occur. The possible side effects of the vaccine are still being studiedin
clinical trials.
WHAT SHOULD I DO ABOUT SIDE EFFECTS?
If you experience a severe allergic reaction, call 9-1-1, or go to the nearest hospital.
Call the vaccination provider or your healthcare provider if you have any side effects
that bother you or do not go away.
Report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System
(VAERS). The VAERS toll-free number is 1-800-822-7967 or report online to
https://vaers.hhs.gov/reportevent.html. Please include either “COMIRNATY (COVID-19
Vaccine, mRNA)” or “Pfizer-BioNTech COVID-19 Vaccine EUA”, as appropriate, in the
first line of box #18 of the report form.
In addition, you can report side effects to Pfizer Inc. at the contact information provided
below.
Website Fax number Telephone number
www.pfizersafetyreporting.com1-866-635-83371-800-438-1985
You may also be given an option to enroll in v-safe. V-safe is a new voluntary
smartphone-based tool that uses text messaging and web surveys to check in with
people who have been vaccinated to identify potential side effects after COVID-19
vaccination. V-safe asks questions that help CDC monitor the safety of COVID-19
vaccines. V-safe also provides second-dose reminders if needed and live telephone
follow-up by CDC if participants report a significant health impact following COVID-19
vaccination. For more information on how to sign up, visit: www.cdc.gov/vsafe.
WHAT IF I DECIDE NOT TO GET COMIRNATY (COVID-19 VACCINE, mRNA) OR
THE PFIZER-BIONTECH COVID-19 VACCINE?
Under the EUA, it is your choice to receive or not receive the vaccine. Should you
decide not to receive it, it will not change your standard medical care.
ARE OTHER CHOICES AVAILABLE FOR PREVENTING COVID-19 BESIDES
COMIRNATY (COVID-19 VACCINE, mRNA) OR PFIZER-BIONTECH COVID-19
VACCINE?
Othervaccines to prevent COVID-19may be available under Emergency Use
Authorization.
5 Revised: 22 September 2021
CAN I RECEIVE THE COMIRNATY (COVID-19 VACCINE, mRNA) OR PFIZER-
BIONTECH COVID-19 VACCINE AT THE SAME TIME AS OTHER VACCINES?
Data have not yet been submitted to FDA on administration of COMIRNATY
(COVID-19 Vaccine, mRNA) or the Pfizer-BioNTech COVID-19 Vaccine at the same
time with other vaccines. If you are considering receiving COMIRNATY (COVID-19
Vaccine, mRNA) or the Pfizer-BioNTech COVID-19 Vaccine with other vaccines,
discuss your options with your healthcare provider.
WHAT IF I AM IMMUNOCOMPROMISED?
If you are immunocompromised, you may receive a third dose of the vaccine. The
third dose may still not provide full immunity to COVID-19 in people who are
immunocompromised, and you should continue to maintain physical precautions to
help prevent COVID-19. In addition, your close contacts should be vaccinated as
appropriate.
WHAT IF I AM PREGNANT OR BREASTFEEDING?
If you are pregnant or breastfeeding, discuss your options with your healthcare
provider.
WILL THE VACCINE GIVE ME COVID-19?
No. The vaccine does not contain SARS-CoV-2 and cannot give you COVID-19.
KEEP YOUR VACCINATION CARD
When you get your first dose, you will get a vaccination card to show you when to
return for your nextdose(s) of the vaccine. Remember to bring your card when you
return.
ADDITIONAL INFORMATION
If you have questions, visit the website or call the telephone number provided below.
To access the most recent Fact Sheets, please scan the QR code provided below.
Global website Telephone number
www.cvdvaccine.com
1-877-829-2619
(1-877-VAX-CO19)
HOW CAN I LEARN MORE?
Ask thevaccination provider.
Visit CDC at https://www.cdc.gov/coronavirus/2019-ncov/index.html.
Visit FDA at https://www.fda.gov/emergency-preparedness-and-response/mcm-
legal-regulatory-and-policy-framework/emergency-use-authorization.
Contact your local or state public health department.
6 Revised: 22 September 2021
WHERE WILL MY VACCINATION INFORMATION BE RECORDED?
The vaccination provider may include your vaccination information in your state/local
jurisdiction’s Immunization Information System (IIS) or other designated system. This
will ensure that you receive the same vaccine when you return for the second dose. For
more information about IISs visit: https://www.cdc.gov/vaccines/programs/iis/about.html.
CAN I BE CHARGED AN ADMINISTRATION FEE FOR RECEIPT OF THE COVID-19
VACCINE?
No. At this time, the provider cannot charge you for a vaccine dose and you cannot be
charged an out-of-pocket vaccine administration fee or any other fee if only receiving a
COVID-19 vaccination. However, vaccination providers may seek appropriate
reimbursement from a program or plan that covers COVID-19 vaccine administration
fees for the vaccine recipient (private insurance, Medicare, Medicaid, Health
Resources & Services Administration \[HRSA\] COVID-19 Uninsured Program for non-
insured recipients).
WHERE CAN I REPORT CASES OF SUSPECTED FRAUD?
Individuals becoming aware of any potential violations of the CDC COVID-19
Vaccination Program requirements are encouraged to report them to the Office of the
Inspector General, U.S. Department of Health and Human Services, at
1-800-HHS-TIPS or https://TIPS.HHS.GOV.
WHAT IS THE COUNTERMEASURES INJURY COMPENSATION PROGRAM?
The Countermeasures Injury Compensation Program (CICP) is a federal program that
may help pay for costs of medical care and other specific expenses of certain people
who have been seriously injured by certain medicines or vaccines, including this
vaccine. Generally, a claim must be submitted to the CICP within one (1) year from the
date of receiving the vaccine. To learn more about this program, visit
www.hrsa.gov/cicp/ or call 1-855-266-2427.
WHAT IS AN EMERGENCY USE AUTHORIZATION (EUA)?
An Emergency Use Authorization (EUA) is a mechanism to facilitate the availability and
use of medical products, including vaccines, during public health emergencies, such as
the current COVID-19 pandemic. An EUA is supported by a Secretary of Health and
Human Services (HHS) declaration that circumstances exist to justify the emergency
use of drugs and biological products during the COVID-19 pandemic.
The FDA may issue an EUA when certain criteria are met, which includes that there are
no adequate, approved, available alternatives. In addition, the FDA decision is based
on the totality of scientific evidence available showing that the product may be effective
to prevent COVID-19 during the COVID-19 pandemic and that the known and potential
benefits of the product outweigh the known and potential risks of the product. All of
these criteria must be met to allow for the product to be used in the treatment of
patients during the COVID-19 pandemic.
This EUA for the Pfizer-BioNTech COVID-19 Vaccine and COMIRNATY will end when
the Secretary of HHS determines that the circumstances justifying the EUA no longer
7 Revised: 22 September 2021
exist or when there is a change in the approval status of the product such that an EUA
is no longer needed.
Manufactured by
Pfizer Inc., New York, NY 10017
Manufactured for
BioNTech Manufacturing GmbH
An der Goldgrube 12
55131 Mainz, Germany
LAB-1451-9.3
Revised: 22 September 2021
Scan to capture that this Fact Sheet was provided to vaccine
recipient for the electronic medical records/immunization
information systems.
Barcode Date: 08/2021
8 Revised: 22 September 2021
How to Replace Your COVID-19 Vaccination Card
To get proof of your COVID-19 Vaccination you may contact the California
Immunization Registry (CAIR) 2-3 weeks after your vaccination. Complete
and submit the 'AuthorizationtoReleaseHealthcareInformation'form to CAIR
by email at CAIRHelpdesk@cdph.ca.gov. Those who need assistance or do
not have access to internet may call (800) 578-7889.
-----
How to Replace Your COVID-19 Vaccination Card
To get proof of your COVID-19 Vaccination you may contact the California
Immunization Registry (CAIR) 2-3 weeks after your vaccination. Complete
and submit the 'AuthorizationtoReleaseHealthcareInformation'form to CAIR
by email at CAIRHelpdesk@cdph.ca.gov. Those who need assistance or do
not have access to internet may call (800) 578-7889.
-----
How to Replace Your COVID-19 Vaccination Card
To get proof of your COVID-19 Vaccination you may contact the California
Immunization Registry (CAIR) 2-3 weeks after your vaccination. Complete
and submit the 'AuthorizationtoReleaseHealthcareInformation'form to CAIR
by email at CAIRHelpdesk@cdph.ca.gov. Those who need assistance or do
not have access to internet may call (800) 578-7889.
Pfizer-BioNTech COVID-19 Vaccine Consent
For Individuals Under 18 Years of Age
Section 1: Information about the child to receive Pfizer-BioNTech COVID-19 Vaccine
(please print):
iddle) Date of Birth (mm/dd/yyyy) Age
Street Address City State Zip
Phone Number
Section 2: Information on the risks and benefits of the Pfizer-BioNTech COVID-19 Vaccine
(Pfizer Vaccine).
Currently the U.S. Food and Drug Administration (FDA) has authorized emergency use of the
Pfizer Vaccine to prevent COVID-19 in individuals 12 years of age and older. The FDA has
not yet approved licensure of vaccine to prevent COVID-19. To learn more about risks,
benefits, and side effects of the Pfizer vaccine, read the
Fact Sheet for Recipients and Caregivers.
Section 3: Consent.
I have reviewed the information on risks and benefits of the Pfizer Vaccine in Section 2 above
and understand the risks and benefits. I agree that:
1.
Pfizer Vaccine.
2. I have the legal authority to consent to have the child named above vaccinated with the
Pfizer Vaccine.
3. I understand I am not required to accompany the child named above to the vaccination
appointment and, by giving my consent below, the child will receive the Pfizer Vaccine
whether or not I am present at the vaccination appointment.
4. I understand that as required by state law (Health and Safety Code, § 120440), all
immunizations will be reported to the California Immunization Registry (CAIR2). I
understand the information in the child's CAIR2 record will be shared with the local health
department and State Department of Public Health, shall be treated as confidential
medical information, and shall be used only to share with each other or as allowed by law.
I may refuse to allow the information to be further shared and can request the CAIR2
record be locked by visiting the Request to Lock My CAIR Record web form.
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.
Name (Last, First, Middle)
Signature Date
Address if different from above
Phone Number if different from above