廣東新冠病毒疫苗接種知情同意書

廣東省新冠病毒疫苗接種知情同意書（中文版）受種者姓名： 性別： 出生日期：年月日【疾病簡介】新型冠狀病毒肺炎（新冠肺炎，COVID-19）為新發(fā)急性呼吸道傳染病。臨床主要表現(xiàn)是發(fā)熱、干咳、乏力，少數(shù)患者伴有鼻塞、流涕、咽痛、結(jié)膜炎、肌痛和腹瀉等癥狀。多數(shù)患者預(yù)后良好，少數(shù)患者病情危重。隨著疫情的蔓延，對全球公眾健康構(gòu)成嚴重威脅。根據(jù)當前新冠肺炎防控需要，為適齡人群開展新型冠狀病毒疫苗接種?！疽呙缱饔谩拷臃N本品可刺激機體產(chǎn)生抗新型冠狀病毒的免疫力，用于預(yù)防新型冠狀病毒引起的疾病。【接種禁忌】疫苗接種禁忌參照產(chǎn)品說明書。通常接種疫苗的禁忌包括：（1）對疫苗或疫苗成分過敏者；（2）患急性疾病者；（3）處于慢性疾病的急性發(fā)作期者；（4）正在發(fā)熱者;（5）妊娠期婦女?！静涣挤磻?yīng)】接種疫苗后發(fā)生局部不良反應(yīng)以接種部位疼痛為主，還包括局部瘙癢、腫脹、硬結(jié)和紅暈等，全身不良反應(yīng)以疲勞乏力為主，還包括發(fā)熱、肌肉痛、頭痛、咳嗽、腹瀉、惡心、厭食和過敏等。【注意事項】接種后留觀30分鐘；如接種后出現(xiàn)不適應(yīng)及時就醫(yī)，并報告接種單位。與其他疫苗一樣，接種本疫苗可能無法對所有受種者產(chǎn)生100%的保護效果。以上內(nèi)容可詳見疫苗說明書?！井惓７磻?yīng)補償】如經(jīng)調(diào)查診斷或鑒定，結(jié)論為異常反應(yīng)或不能排除，按有關(guān)規(guī)定進行補償。請您認真閱讀以上內(nèi)容，如實提供受種者的健康狀況和是否有接種禁忌等情況。如有疑問請咨詢醫(yī)療衛(wèi)生人員。本人已了解疫苗的品種、作用、禁忌、不良反應(yīng)以及現(xiàn)場留觀等注意事項，并如實提供健康狀況和是否有接種禁忌等情況。監(jiān)護人/受種者（簽名）： 日期：年月日監(jiān)護人與受種者的關(guān)系：。母親。父親。其他（請注明）醫(yī)療衛(wèi)生人員（簽名）： 日期：年月 日為了保證安全有效地接種，醫(yī)護人員將詢問以下健康信息并提出醫(yī)學(xué)建議。發(fā)熱、各種急性疾病、慢性疾病急性發(fā)作期。是。否對疫苗或疫苗成分過敏，既往發(fā)生過疫苗嚴重過敏反應(yīng)。是。否未控制的癲癇、腦病、其他進行性神經(jīng)系統(tǒng)疾病。是。否妊娠期婦女。是。否嚴重慢性疾病*。是。否*號表示本疫苗接種慎用情況醫(yī)學(xué)建議：您此次新型冠狀病毒滅活疫苗接種。建議接種。推遲接種。不宜接種醫(yī)護人員： 日期：年—月—日聯(lián)系電話： 接種單位（蓋章）：本人已接受健康詢問，同意醫(yī)學(xué)建議。受種者/監(jiān)護人： 日期：年—月—日InformedConsentforCOVID-19Vaccination

inGuangdongNameofRecipient: Gender: DateofBirth: (yyyy/mm/dd)[BriefOverview]CoronavirusDisease2019(COVID-19)isanemergingandacuterespiratoryinfectiousdisease.Itsclinicalmanifestationsmainlyincludefever,drycoughandfatigue.Afewpatientsmaysufferfromcongestion,runnynose,sorethroat,conjunctivitis,muscleachesordiarrheaamongothersymptoms.Amajorityofpatientspresentagoodprognosiswhilefewmaybeincriticalcondition.Asthepandemicspreadsglobally,COVID-19hasposedaseriousthreattopublichealth.InabidtostrengthenCOVID-19preventionandcontrol,COVID-19vaccinationiscurrentlyavailableforage-appropriatepopulationgroups.[VaccineEfficacy]Thisvaccinecouldengagethebody,simmuneresponseagainstCOVID-19andthuscouldbeusedtopreventdiseasescausedbyCOVID-19.[Contraindications]Pleaserefertothevaccineproductinstructionsforspecificinformationofcontraindications.Thefollowinggroupsareusuallynotincludedintheeligibilityrangeforthevaccine:Individualswithallergiestothevaccineoranyingredientsofthevaccine;Individualswhoaresufferingfromacutediseases;Individualswhoaresufferingfromacutephasesofchronicillnesses;Individualswithafever;Womenduringpregnancy.[AdverseReactions]Afterthevaccination,injectionsitereactionsmainlyincludeinjectionsitepain,whilesomemighthaveinjectionsiteitching,swelling,hardnessorredness,etc.;systemicreactionsmainlyincludefatigue/weakness,whilesomemighthavefever,musclepain,headache,cough,diarrhea,nausea,anorexiaorallergicreactions.[Notice]Therecipientsshallstayattheobservationareaofthevaccinationfor30minutesafterbeinginoculated.Ifanyadversereactionoccurs,pleasetimelyseekmedicaladviceandreporttothevaccinationsite.Pleasekindlybenotedthatthisvaccine,likeothers,mightnotguarantee100%protectiontoallrecipients.Pleaserefertothevaccineproductinstructionsforspecificdetails.[AdverseEventsFollowingImmunization(AEFI)Compensation]Ifvaccine-associatedadverseeventsarediagnosed,orthepossibilityofsuchadverseeventscannotbeexcludedafterdiagnosisormedicalevaluation,compensationwillbeprovidedaccordingtoapplicableguidelines.PleasereadtheaboveInformedConsentandfaithfullyprovidehealthandcontraindicationinformationoftherecipient.Pleaseconsultmedicalorhealthcarestaffwhenanyquestionsarise.Ihavefullyunderstoodthetype,efficacy,contraindications,adversereactionsandthenoticeofstayingonsiteforatleast30minutesafterbeinginoculated,etc.IwillprovidethemedicalpractitionerwithfaithfulinformationaboutmyhealthconditionsandaboutwhetherornotIhavecontraindicationstothevaccination.Guardian/Recipient(Signature): Date: (yyyy/mm/dd)Therelationshipbetweentheguardianandtherecipient:oMother oFather oOthers(Pleasestatehere)MedicalPractitioner(Signature): Date: (yyyy/mm/dd) Inordertoensurethesafetyandefficacyofthevaccination,themedicalpractitionerswillenquireaboutthefollowinginformationandprovidemedicaladviceaccordingly.Areyousufferingfromafever,anyacutediseasesoracutephasesofanychronicillnesses?oYesoNoAreyouallergictothevaccineoranyingredientsofthevaccine,orhaveyouhadanysevereallergicreactionstoanyvaccinesbefore?oYesoNoAreyouhavinganyunmanagedepilepsy,encephalopathyorotherprogressiveneurologicaldiseases?oYesoNoAreyoupregnant?Areyousufferingfromanychronicdiseases?*oYesoNooYesoNo*showsthatvaccinationshouldbeprudentlyassessedifyouhavethiscondition.MedicalAdvice:Thevaccinationisorecommendedorecommendedtodelayonotrecommendedtotherecipient.MedicalPractitioner: Date: (yyyy/mm/dd)Tel: Institution(Stamp):IhavebeenenquiredaboutmyhealthinformationandIacceptthemedicaladvice.Date:Recipient/Guardian:Date:(yyyy/mm/dd)普巖乜3杳衛(wèi)星號叫。|己1仝野任書香若9R

（廣東省新型冠狀病毒疫苗接種知情同意書）【 】( 19,COVID-19). 19【】.【】.①.②TOC\o"1-5"\h\z③ .④⑤ ^【】1】 30100%

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*（^本^^^^^接槿布控之馬7豈狀況髡熟、各不重內(nèi)急性病、慢性病、慢性病內(nèi)急性髡作期^^^^又（^^②成分仁^^^早一^^4、謾去仁。^\、了^兒早一反^^^而4未制御內(nèi)癲癩、月鹵癥、他內(nèi)迤行性神^系疾患內(nèi)而己方妊娠期^中內(nèi)女性重度慢性病*。是 。否。是 。否。是 。否。是 。否。是 。否醫(yī)學(xué)上內(nèi)了卜八彳久：今回新型二口^^^^^^^接^^?？?。延期。中止醫(yī)瘴闋保者： 期日：年—月—日^^番號： 接槿檄橫（捺?。罕救薧健康相^在受^^上^、二內(nèi)了卜八彳久仁同意L殺To受槿者?彼冕人： 期日： 年—月Consentementeclairepourlavaccination

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(廣東省新型冠狀病毒疫苗接種知情同意書)NomduReceveur: Sexe: Datedenaissance:(aaaa/mm/jj)[Introductiondelamaladie]Lapneumoniecauseeparlenouveaucoronavirus(COVID-19)estunenouvellemaladieinfectueuserespiratoireaiguee.Lesprincipalesmanifestationscliniquessontlafievre,latouxsecheetlafatigue.Unpetitnombredepatientssontaccompagnesdebouchonnasal,d,ecoulementnasal,dedouleursdepharynx,deconjonctivite,demyodynieetdediarrahee.Lepronosticestfavorablepourlaplupartdespatients,tandisqu,unpetitnombred,entreeuxpourraientdansunetatcritique.Lapropagationdel,epidemieconstitueunemenacegravepourlasantepubliquemondiale.EnfonctiondesbesoinsactuelsdepreventionetdecontroleduCOVID-19,lavaccinationcontreleCOVID-19pourlapopulationenageapproprieestactuellementencours.[Efficaciteduvaccin]L,inoculationstumuleledeveloppementd,uneimmunitecontreleCOVID-19etsertaprevenirlesmaladescauseesparleCOVID-19.[Contre-indications]Lescontre-indicationsconcernantlavaccinationsereferentaladescriptionduvaccin.Lespopulationssuivantesnedevraientpasetrevaccinees:Personnesallergiquesauvaccinouasescomposants;Personnessouffrantdemaladiesaiguees;Personnesenphaseaigueedemaladieschroniques;Personnessouffrantdelafievre;Femmesenceintes.[Effetsindesirables]Apreslavaccination,leseffetsindesirablespartielocauxsontdominespardesdouleurssurlesited,injection,ainsiquepardesdemageaisonslocales,desgonflements,desstenosesetdesrouges.Leseffetsindesirablessysteatiquessontdominesparlafatigueetlafaiblesse,etcomprennentegalementlafievre,lesdouleursmusculaires,lesmauxdetete,latoux,ladiarrhee,lesnausees,l,anorexieetlesallergies.[Tentions]Lespersonnesvaccineessontrecommendeesaresterdanslazoned,observationpendantaumoins30minutesapresl,inoculation.Siuneffetindesirablesurvientapreslavaccination,consulterimmediatementunmedecinetsignaleral,unitedevaccination.Commepourlesautresvaccins,lavaccinationpeutnepasassureruneprotection100%atouslesreceveurs.Veuillezrefereraladescriptionduvaccinpourplusdedetails.[Compensationdesreactionsanormales]Sideseffetsindesirablesindesirablesliesauvaccinsontdiagnostiques,ousilapossibilitedetelseffetsindesirablesnepeutetreexclueapresdisgnosticouevaluationmedicale,unecompensationseraaccordeeconformementauxdispositionspertinentes.VeuillezlireattentivementleConsentementeclairesi-dessusetfournirfidelementdesinformationstellesquel,etatdesantedureceveuretl,existencedecontre-indicationsenmatieredevaccination.Veuillezconsulterlepersonnelmedicalencasdequestions.J'aieteinformedelatypeduvaccin,desesefficacites,desescontre-indications,deseseffetsindesirablesainsiquelebesoind,observationpendantaumoins30minutessurleterrainapresl,inoculation,etc.Jevaisfournirfidelementdesinformationspersonnellestellesquel,etatdesanteetl,existencedecontre-indicationsenmatieredevaccination.Tuteur(trice)/Receveur(Signature): Date: (aaaa/mm/jj)Relatione