广东省新冠病毒疫苗接种知情同意书Word格式文档下载.docx

1、请您认真阅读以上内容，如实提供受种者的健康状况和是否有接种禁忌等情况。如有疑问请咨询医疗卫生人员。本人已了解疫苗的品种、作用、禁忌、不良反应以及现场留观等注意事项，并如实提供健康状况和是否有接种禁忌等情况。监护人/受种者（签名）： 日期：监护人与受种者的关系：母亲 父亲 其他（请注明）_医疗卫生人员（签名）：为了保证安全有效地接种，医护人员将询问以下健康信息并提出医学建议。发热、各种急性疾病、慢性疾病急性发作期 对疫苗或疫苗成分过敏，既往发生过疫苗严重过敏反应未控制的癫痫、脑病、其他进行性神经系统疾病妊娠期妇女严重慢性疾病*是 否* 号表示本疫苗接种慎用情况医学建议：您此次新型冠状病毒灭活疫苗

2、接种 建议接种 推迟接种 不宜接种医护人员：_年_月_日联系电话： 接种单位（盖章）：本人已接受健康询问，同意医学建议。受种者/监护人： 日期：Informed Consent for COVID-19 Vaccination in GuangdongName of Recipient: Gender: Date of Birth: （yyyy/mm/dd）Brief Overview Coronavirus Disease 2019 （COVID-19） is an emerging and acute respiratory infectious disease. Its clinical

3、 manifestations mainly include fever, dry cough and fatigue. A few patients may suffer from congestion, runny nose, sore throat, conjunctivitis, muscle aches or diarrhea among other symptoms. A majority of patients present a good prognosis while few may be in critical condition. As the pandemic spre

4、ads globally, COVID-19 has posed a serious threat to public health. In a bid to strengthen COVID-19 prevention and control, COVID-19 vaccination is currently available for age-appropriate population groups. Vaccine Efficacy This vaccine could engage the bodys immune response against COVID-19 and thu

5、s could be used to prevent diseases caused by COVID-19.Contraindications Please refer to the vaccine product instructions for specific information of contraindications. The following groups are usually not included in the eligibility range for the vaccine:1.Individuals with allergies to the vaccine

6、or any ingredients of the vaccine;2.Individuals who are suffering from acute diseases;3.Individuals who are suffering from acute phases of chronic illnesses;4.Individuals with a fever;5.Women during pregnancy. Adverse ReactionsAfter the vaccination, injection site reactions mainly include injection

7、site pain, while some might have injection site itching, swelling, hardness or redness, etc.; systemic reactions mainly include fatigue/weakness, while some might have fever, muscle pain, headache, cough, diarrhea, nausea, anorexia or allergic reactions. Notice The recipients shall stay at the obser

8、vation area of the vaccination for 30 minutes after being inoculated. If any adverse reaction occurs, please timely seek medical advice and report to the vaccination site. Please kindly be noted that this vaccine, like others, might not guarantee 100% protection to all recipients. Please refer to th

9、e vaccine product instructions for specific details. Adverse Events Following Immunization （AEFI） Compensation If vaccine-associated adverse events are diagnosed, or the possibility of such adverse events cannot be excluded after diagnosis or medical evaluation, compensation will be provided accordi

10、ng to applicable guidelines.Please read the above Informed Consent and faithfully provide health and contraindication information of the recipient. Please consult medical or healthcare staff when any questions arise. I have fully understood the type, efficacy, contraindications, adverse reactions an

11、d the notice of staying on site for at least 30 minutes after being inoculated, etc. I will provide the medical practitioner with faithful information about my health conditions and about whether or not I have contraindications to the vaccination.Guardian/Recipient （Signature）: Date: （yyyy/mm/dd）The

12、 relationship between the guardian and the recipient: Mother Father Others （Please state here）_Medical Practitioner （Signature）:In order to ensure the safety and efficacy of the vaccination, the medical practitioners will enquire about the following information and provide medical advice accordingly

13、.Are you suffering from a fever, any acute diseases or acute phases of any chronic illnesses?Are you allergic to the vaccine or any ingredients of the vaccine, or have you had any severe allergic reactions to any vaccines before?Are you having any unmanaged epilepsy, encephalopathy or other progress

14、ive neurological diseases?Are you pregnant?Are you suffering from any chronic diseases?*Yes Noshows that vaccination should be prudently assessed if you have this condition.Medical Advice: The vaccination is recommended recommended to delay not recommended to the recipient.Medical Practitioner: Date

15、:Tel: Institution （Stamp）:I have been enquired about my health information and I accept the medical advice.Recipient/Guardian: （yyyy/mm/dd） （广东省新型冠状病毒疫苗接种知情同意书） : : : 【 】 （19,COVID-19） . . . 19 .【】 .【】 . . . . . . .【】 , , , , , , , , , , .【】 30 . . 100% . .【】 . . . , , , ./ （）: : : （） : : .* ., , ,

16、* : : : （）: .（）: 広東省新型接種関了承同意書被接種者名前： 性別： 生年月日：【新型概況】新型肺炎（新型、COVID-19）新種急性気道伝染病。臨床症状発熱、空咳、体主、鼻詰、鼻水、喉痛、結膜炎、筋肉痛、下痢伴患者少数出。、大部分患者回復一方、重篤症状人少数。感染病広、全世界人健康大脅威。現在、新型制御基、適齢者新型接種行。【効果】本接種新型対抗免疫力生体刺激、新型引起病気予防使。【接種禁忌】接種禁忌事項製品説明書参考。普通、接種禁忌以下：（1）或成分方。（2）急性疾患持患者。（3）慢性病急性発作期方。（4）発熱者。（5）妊娠期間中女性。【副反応】接種後出局所副反応接種部位疼痛

17、主、一部、腫脹、凝紅暈発赤含。全身副反応疲労体主、発熱、筋肉痛、頭痛、咳、下痢、吐気、食欲不振含。【注意事項】接種後30分間現場待機観察。接種後体具合悪場合即時病院行上接種機構伝。他同、本接種接種者100予防効果保障。詳説明書参考。【異常反応補償】調査診断或鑑定異常反応又排除不可能判明場合、関連規定基補償行。以上内容覧上、被接種者健康接種禁忌等実状況隠提供。疑問場合医療関係者問合。当方既品種、効果、禁忌、不良反応及現場観察等注意事項理解、健康接種禁忌等状況事実通提供。後見人被接種者（）： 期日：後見人被接種者関係：母 父 他（記入）_医療関係者（）： 期日：安全有効接種行、医療関係者以下健康情

18、報確認、医学上提出。発熱、各種急性病、慢性病、慢性病急性発作期又成分、過去反応経験未制御癲癇、脳症、他進行性神経系疾患方妊娠期間中女性重度慢性病* 本接種控状況医学上：今回新型接種 可 延期 中止医療関係者： 期日：電話番号： 接種機構（捺印）：本人健康相談受上、同意。受種者後見人：Consentement clair pour la vaccination contre le COVID-19 dans le GuangdongNom du Receveur: Sexe: Date de naissance:（aaaa/mm/jj）Introduction de la maladieLa p

19、neumonie cause par le nouveau coronavirus（COVID-19） est une nouvelle maladie infectueuse respiratoire aigue. Les principales manifestations cliniques sont la fivre, la toux sche et la fatigue. Un petit nombre de patients sont accompagns de bouchon nasal, dcoulement nasal, de douleurs de pharynx, de

20、conjonctivite, de myodynie et de diarrahe. Le pronostic est favorable pour la plupart des patients, tandis quun petit nombre dentre eux pourraient dans un tat critique. La propagation de lpidmie constitue une menace grave pour la sant publique mondiale. En fonction des besoins actuels de prvention e

21、t de contrle du COVID-19, la vaccination contre le COVID-19 pour la population en ge appropri est actuellement en cours. Efficacit du vaccin Linoculation stumule le dveloppement dune immunit contre le COVID-19 et sert prvenir les malades causes par le COVID-19.Contre-indications Les contre-indicatio

22、ns concernant la vaccination se rfrent la description du vaccin. Les populations suivantes ne devraient pas tre vaccines:1. Personnes allergiques au vaccin ou ses composants;2. Personnes souffrant de maladies aigues3. Personnes en phase aigue de maladies chroniques4. Personnes souffrant de la fivre5. Femmes enceintes.Effets indsirablesAprs la vaccination, les effets indsirables partielocaux sont domins par des douleurs sur le site dinjection, ainsi que par des dmageaisons locales, des gonflements, des stnoses et des rouges. Les effets indsirables systatiques sont domins par la