广东新冠病毒疫苗接种知情同意书

广东省新冠病毒疫苗接种知情同意书（中文版）受种者姓名： 性别： 出生日期：年月日【疾病简介】新型冠状病毒肺炎（新冠肺炎，COVID-19）为新发急性呼吸道传染病。临床主要表现是发热、干咳、乏力，少数患者伴有鼻塞、流涕、咽痛、结膜炎、肌痛和腹泻等症状。多数患者预后良好，少数患者病情危重。随着疫情的蔓延，对全球公众健康构成严重威胁。根据当前新冠肺炎防控需要，为适龄人群开展新型冠状病毒疫苗接种。【疫苗作用】接种本品可刺激机体产生抗新型冠状病毒的免疫力，用于预防新型冠状病毒引起的疾病。【接种禁忌】疫苗接种禁忌参照产品说明书。通常接种疫苗的禁忌包括：（1）对疫苗或疫苗成分过敏者；（2）患急性疾病者；（3）处于慢性疾病的急性发作期者；（4）正在发热者;（5）妊娠期妇女。【不良反应】接种疫苗后发生局部不良反应以接种部位疼痛为主，还包括局部瘙痒、肿胀、硬结和红晕等，全身不良反应以疲劳乏力为主，还包括发热、肌肉痛、头痛、咳嗽、腹泻、恶心、厌食和过敏等。【注意事项】接种后留观30分钟；如接种后出现不适应及时就医，并报告接种单位。与其他疫苗一样，接种本疫苗可能无法对所有受种者产生100%的保护效果。以上内容可详见疫苗说明书。【异常反应补偿】如经调查诊断或鉴定，结论为异常反应或不能排除，按有关规定进行补偿。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：年月日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）： 日期：年月 日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。是。否对疫苗或疫苗成分过敏，既往发生过疫苗严重过敏反应。是。否未控制的癫痫、脑病、其他进行性神经系统疾病。是。否妊娠期妇女。是。否严重慢性疾病*。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接种。建议接种。推迟接种。不宜接种医护人员： 日期：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：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)普岩乜3杳卫星号叫。|己1仝野任书香若9R

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了承同意善被接槿者名前： 性别： 生年月日：年月日【新型二口十G概况】新型二口十^彳儿久肺炎（新型口口十、COVID-19）（^新不重急性气道彳云染病^^4来寸。陶床症状^髡热、空咳、体^^马^^主^^G占太;H、鼻^来^、鼻水、喉内痛办、结膜炎、筋肉痛、下痢^^在伴5患者^少数出来寸。杀｛、大部分内患者^上L、回彳复力^^^^一方、重篇玄症状仁力、力、n^L、马人^少数^、来寸。感染病内区力;^^o九乙、全世界内人々内健康仁大岂玄耆威在^/c^LX^^To现在、新型二口十制御内二一犬仁基于舌、逾龄者仁新型二口^^^^^^接不重在行L、杀寸。【^^^^^效果】本^^^^^接不重^新型口口^^彳心久仁文寸抗T马免疫力^生来;H马上5U体在刺激L、新型二口^^彳儿久^引舌起二LC病家在予防T马内仁使^^杀T。【接槿禁忌】^^^^接不重内禁忌事项^^品^明善在^参考＜^^L、。普通、^^^^接木重内禁忌^以下占玄nXL、杀T：（1）^^^^或⑺^^G成分仁^^^早一力:而己方。（2）急性疾患在持o患者。（3）慢性病内急性髡作期仁而马方。（4）髡熟者。（5）妊娠期^中内女性。【副反宓】^^^^接不重彼仁出马局所内副反加^接不重部位内疼痛在主占LX、一部内力、⑶太、月重眼、凝4占系工量•髡赤^^、^含来;H杀T。全身内副反庙占LX疲劳占体^^马太在主仁、髡熟、筋肉痛、^痛、咳、下痢、吐舌气、食欲不振占了^^早一^^、^含来;H杀寸。【注意事项】接不重^^30分^^埸^待檄L^^^察＜^太L、。接不重彼仁体内具合力：总＜玄马埸合^即日寺仁病院仁行0^上^接木重檄情仁^彳云之P＜^太L、。他^^^^^占同C上^仁、本^^^^^接不重^^^^内接不重者仁100%内予防效果在保障^^兴过人。辞L＜（^^夕^^^明善在二、参考＜^^L、。【昊常反必襁僭】^查粉断或L、（^^定仁上^^^常反庙又^排除不可能占判明太:H｛埸合、阕速规定仁基于岂祷慎在行L、杀守。以上内内容在杀C的仁二、^^^^｛上^、被接槿者内健康^接槿禁忌等^^卜、^^^内状况在隐太^^提供LX＜^^^o疑周G埸合^医瘴阕保者仁扮冏L、合^^＜^雉、。当方^既仁^^^^②品不重、效果、禁忌、不良反庙及^^埸^察等内注意事项在上＜理解L、健康占接槿禁忌等②状况在事夹通^^提供L来L^。接兄人•被接不重者（廿彳^）: 期日：年月日彼兄人占被接不重者内阕保：。母。父。^G他（二二^^言己入）医瘴阕保者（廿彳^）： 期日：年月日安全^0有效玄接槿在行^^的仁、医瘵阕保者^以下内健康情辍^^^、乙碓熬L、医学上内了 久在提出L

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(广东省新型冠状病毒疫苗接种知情同意书)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