California Dental Association Updated November 18, 2022. Ask a family member or friend to help you schedule a vaccination appointment if you cant get vaccinated on site. xmlns: "http://www.w3.org/2000/svg" hM+DQs&D)IvJ,ld&Rdeam+Kx)RJ6I{nfn~={^9cHX!Rfrr\U,\"GwRUa j[H>*xE*,Kq\^xCR]D8/Cn>b*0qngrE28l;#?xFpJl][y)`}]9{L\evvHv# It is recommended that symptoms of acute illness should. Before administering a COVID-19 vaccine with Emergency Use Authorization (EUA), the provider must provide the approved EUA fact sheet (or Vaccine Information Sheet, as applicable) to each vaccine recipient, the adult caregiver accompanying the recipient (as applicable), or other legal representative (as applicable). A client consent form for salon services is a template used by salons to acquire the legal rights to administer COVID-19 vaccinations during a COVID-19 pandemic. 7201 0 obj
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Medical consent is not required by federal law for COVID-19 vaccination in the United States. It just means additional questions must be asked. Start collecting your participants' liability release waiver for this pandemic using this COVID-19 Liability Release Waiver Template. If youd like to keep patient information private, Jotform offers HIPAA compliance, keeping this form and your medical practice protected from damages. Just connect your device to the internet and load your form and start collecting your liability release waiver. 0
COVID-19 vaccines and other vaccines may be administered without regard to timing (same visit) with the exception of JYNNEOS vaccine. Its been a long time coming, and patients are anxious to get their vaccines administered as quickly as possible so make the scheduling process as seamless as possible with Jotforms free online COVID-19 Vaccine Appointment Form. CDC recommends everyone stay up to date with COVID-19 vaccines for their age group: People who are moderately or severely immunocompromised have. In our study, we aimed to determine the titers of anti-S-RBD antibody and surrogate . www.publix.com. Copies of the adult consent form (PDF version) are available to order using product code COV2020376V2. You can even convert submissions into PDFs automatically, easy to download or print in one click. A British Sign Language (BSL) video explaining the COVID-19 vaccination consent form is available to view and download. Please note that all policies and forms that we provide should be reviewed by your legal counsel to ensure full compliance with your local, state and federal regulations and that is in accordance with your specific business needs. COVID-19 vaccine providers should consult with their own legal counsel for state or territorial requirements related to consent; compliance with all applicable state and territorial laws is required under the CDC Provider Agreement. ObjectivesThis study aimed to assess the duration of humoral responses after two doses of SARS-CoV-2 mRNA vaccines in patients with inflammatory joint diseases and IBD and booster vaccination compared with healthy controls. A COVID-19 vaccine registration form is used by medical practices to sign up patients for the COVID-19 vaccine. If you have additional questions about how to get a COVID-19 vaccine, talk with your healthcare provider. Is this your first, second or 3rd (for immunocompromised) primary series dose? I believe I understand the benefits and risks of influenza vaccination and request vaccination to be administered to me, or the above named for whom I am authorized to make this request. The fact sheet/information sheet explains risks and benefits of the particular COVID-19 vaccine and what to expect but is not a consent document. In response to inquiries about medical consent surrounding the administration of a booster shot of Pfizer-BioNTech COVID-19 vaccine to residents in long-term care (LTC) settings at least five months after their Pfizer-BioNTech primary series1, the Centers for Disease Control and Prevention (CDC) has developed the following responses to frequently asked questions (FAQs). ir*hR4WUR6.mP*w%l*RT 524 0 obj
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I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain right to privacy regarding my protected health information. If yes, please indicate when the symptoms started or date, After a COVID-19 infection, it is strongly recommended to wait 8, individuals considered moderately to severely immunocompromised. Each time you mail an envelope, you must send an email to Phisisp@gnb.ca notifying them that an envelope has been sent and provide the following information: Note: These administration forms do not need to be completed for COVID-19 vaccines administered by Pharmacists entering the immunization information in the Drug Information System (DIS) or. A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. This vaccine has not undergone CDC's recommendations now allow for this type of mix and match dosing for booster shots. Alternatively, the consent-giver must be an individual with the legal capacity to consent for the Patient, such as a parent, legal guardian, or authorized health care surrogate. This file may not be suitable for users of assistive technology. View responses and get the information you need from patients with a free online COVID-19 Booster Vaccine Consent Form. We also use cookies set by other sites to help us deliver content from their services. You may be. A $25 docnation is suggested if you do not have insurance or we are not able to bill your insurance. You will be subject to the destination website's privacy policy when you follow the link. Convert to PDFs instantly. A COVID-19 booster vaccine consent form is used by medical organizations to collect personal and medical information from patients who are interested in the COVID-19 booster vaccine. Older adults and people with certain health conditions are more likely to get very sick from COVID-19. by Physicians/Nurse Practitioners who submit billing to medicare. This COVID-19 Liability Release Waiver Template is the quick consent form that you can use for your clients or customers. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. An emancipated minor may consent for him/herself. Are you feeling well today, and do you have a bodily temperature . or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent form. CDC twenty four seven. Botika LTC may not have all three COVID-19 vaccines at the time of clinic. Refer to JYNNEOS Vaccine | Monkeypox | Poxvirus | CDC Refer Summary Turns form submissions into PDFs automatically. Individuals may be safely immunized without discontinuation of their anticoagulation therapy. No coding required.
Vaccine Intake Consent Form Clinic ID Clinic Name Telephone Store Number Address City State Zip Last Name First Name Date of Birth Gender . Providers should consult their legal counsel on such requirements. }. Further, I understand that a booster dose of COVID-19 vaccine is recommended for those 6 months-4 years of age who received Moderna as a primary series and those 5 years of age and older at least 2 months following the completion of a COVID-19 vaccine primary series or a monovalent booster dose to increase my protection. Dont worry we wont send you spam or share your email address with anyone. Please check with the pharmacy prior to . Phone Number: * w~qWpWW~'W\5O^_|W/oo~~7~>xW^Wo~G+WW^]?AQ?=|f_}v&o8j/_\]|?o._omx|_zL+]|w#ZNOn^%#~u{'/^{H{qm_#C!}*cWS8db:%J0U#P>^zhe_k. COVID-19 vaccines can help protect against severe illness, hospitalization and death from COVID-19. Consent forms. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Author: New York State Department of Health Created Date: 20221118202434Z . hbbd```b``fA$\"rA$7akVz Copies of printed publications and the full range of digital resources to support the immunisation programmes can now be ordered and downloaded online. I have had a chance to ask questions that were answered to my satisfaction. Some people may have a preference for the vaccine type that they originally received, and others may prefer to get a different booster. Residents (or their medical proxies) get a. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Free intake form for massage therapists. You have rejected additional cookies. vaccine and consent to vaccination was obtained. Yes No Date: If applicable) 18. Check back for updates/availability, Influenza High-Dose (Ages 65+) expected to be available mid-October. If you need to change the look or design of your chosen Coronavirus Response Form template, use our drag-and-drop Form Builder to make necessary changes in seconds. A COVID-19 Liability Release Waiver is a document that intends to acquire the consent of the client or customer for a liability release waiver. The name "Jotform" and the Jotform logo are registered trademarks of Jotform Inc. Feel free to sync submissions to other accounts youre already using, such as Google Drive, Dropbox, Box, Airtable, and more, with our 100+ free-form integrations. A COVID-19 liability waiver is used to release a business of any legal responsibility if its customers contract the coronavirus while buying the business products or receiving the business services. Follow CDC requirements with this free passenger attestment form for airlines and aircraft operators. Make sure massage clients are healthy before their spa appointment. 4) I will immediately alert the pharmacist of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. Go to My Forms and delete an existing form or upgrade your account to increase your form limit. Novavax Primary Series (dose 1 and 2) can ONLY be administered to patients who have NEVER had a previous Covid vaccine, Novavax Boosters can ONLY be administered to patients who have had a primary series AND NO FURTHER BOOSTERS, **9/19/22 -Moderna Bivalent Booster currently unavailable. 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. No matter which industry you belong to, keep your customers and your business safe during the coronavirus pandemic with a free online COVID-19 Liability Waiver that helps you collect e-signatures fast . Copies of. CDC has updated select ways to operate healthcare systems effectively in response to COVID-19 vaccination. Collect data on any device. Alabama Immunization Consent Form Florida Immunization Consent Form Georgia Immunization Consent Form North Carolina Immunization Consent Form These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. A written form is not needed if a state law allows for oral consent and the organization/provider does not otherwise require it. I understand that at this time, some COVID-19 vaccines require 2 doses given 21-28 days apart dependent on the . If you choose not insured, American Indian/Native Alaskan, or Underinsured, you child qualifies for VFC & no payment is reuqired, but donations are accepted. If you're having problems using a document with your accessibility tools, please contact us for help. As a web-based form, you eliminate the waste of printing and waste of physical storage space. Great for remote medical services. And with our 100+ integrations, you can send collected responses to your CRM or storage service of choice. The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. Receive submissions for COVID-19 test reports from your staff for your company or organization online. Collect COVID-19 vaccine registrations online. You may choose to upload the front and back of your insurance card, or enter the appropriate card information below. I have had a copy of the Emergency Use Authorization for the COVID-19 vaccine made available to me. With this free online COVID-19 liability waiver, businesses of any industry can seamlessly accept signed liability waivers online. I have read, or have had explained to me, the information about influenza disease and the influenza vaccine. Easy to customize, share, and embed. Residents and their families can ask a LTC provider about the current COVID-19 vaccination rate among their staff and residents. Get a dedicated support team with Jotform Enterprise. Full Name: * First Name Ml Last Name. fill: "none" Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. These forms must be placed in an envelope, seal the flap. Sacramento, CA 95814 (e.g. You have accepted additional cookies. Allowable consent includes: Parent/guardian accompanies the minor in person. Novavax Primary Series (dose 1 and 2) can ONLY be administered to patients who have NEVER had a previous Covid vaccine . version of this document in a more accessible format, please email, Check benefits and financial support you can get, Find out about the Energy Bills Support Scheme, COVID-19 vaccination consent form for adults who are able to consent (open source version), COVID-19 vaccination consent form for adults who are able to consent (MS Word version), COVID-19 vaccination consent form for adults who are able to consent (PDF version), COVID-19 vaccination consent form letter for adults who are able to consent (open source version), COVID-19 vaccination consent form letter for adults who are able to consent (MS Word version), COVID-19 vaccination: consent forms and letters for care home residents, COVID-19 vaccination: resources for schools and parents, COVID-19 vaccination: consent form for children and young people or parents, COVID-19 vaccination: easy-read consent form for adults. Copyright 1996-2023 California Dental Association. HIPAA compliance option. 1201 K Street, 14th Floor We use some essential cookies to make this website work. and write initials on the flap. You can also upload your logo, include extra questions, and further personalize the design or sync submissions to third-party apps like Google Calendar, Google Sheets, and Slack with our 100+ free form integrations! that a booster dose of COVID- 19 vaccine is recommended at least 2 months following the completion of a COVID-19 vaccine . Fill out on any device. Unless I provide the applicable Provider with a signed Opt-Out Form, I . We are thankful for
To receive email updates about COVID-19, enter your email address: We take your privacy seriously. Copy this COVID-19 Vaccination Declination Form to your Jotform account. The letter templates can be adapted to suit the. These templates are suggested forms only. COVID-19 vaccines, including boosters, are effective at protecting people from getting seriously ill, being hospitalized, and dying. A consent form is filled out for the Pfizer/BioNTech Covid-19 vaccine. COVID-19 Moderna BIVALENT Booster Appointment Form for Tuesday 3/14/23 You MUST bring your vaccine card to your booster shot appointment, your drivers license or ID, and your insurance card(s). The COVID-19 Provider Agreement contains the following requirements: Explaining the risks and benefits of any treatment to a patient in a way that they understand is the standard of care. 469 0 obj
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Use this Negative COVID-19 Test Reporting Form template and make your receiving process simple and manageable. People can report suspected cases of COVID-19 in their workplace or community. 6945 0 obj
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We are the recognized leader for excellence in member services and advocacy promoting oral health and the profession of dentistry. A health declaration form is a document that declares the health of a person to the other party. Get all these features here in Jotform! These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Add your logo, change the background image, or add more form fields to collect clients medical history at the same time. Cookies used to make website functionality more relevant to you. Thank you for taking the time to confirm your preferences. This validation (double check) must be done and documented prior to sending (for entry) or entering the information. ColindaleLondonNW9 5EQ. No coding. Some COVID-19 vaccination providers may require written, email, or verbal consent from recipients before getting vaccinated. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Wellmark BC/BS or United Health Care Insurance Information. Build your form in seconds for receiving COVID-19 vaccination card information from your patients. Nonprofits can collect volunteer applications online with our free COVID-19 Volunteer Application Form. Then mail the envelopes to: 520 King Street, 4th Floor Reception Fredericton, NB E3B 5G8. With a free online COVID-19 Booster Vaccine Consent Form, you can collect patient consent for your medical practice! These FAQs are intended to clarify that medical consent is not required by federal law for COVID-19 vaccination in the United States. This document provides general information related to the law but does not provide legal advice. Masking is required at City-run clinics. * Flu Injection COVID-19 Flu & COVID. that a booster dose of COVID- 19 vaccine is recommended at least 2 months following the completion of a COVID-19 vaccine . Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. To help us improve GOV.UK, wed like to know more about your visit today. Easy to personalize, embed, and share. Author: Amanda Lusk Created Date: 4/29/2021 12:02:20 PM . Together, we champion better oral health care for all Californians. If you answer yes to any question, it does not necessarily mean your child should not be vaccinated. A COVID-19 vaccine appointment form is used by medical practices to schedule COVID-19 vaccine appointments. They help us to know which pages are the most and least popular and see how visitors move around the site. But, the next time you travel to Florida, Georgia, Alabama, South Carolina, North Carolina, Tennessee, or Virginiamake sure you visit the store where shopping is a pleasure during your stay. We take your privacy seriously. Immunisation PublicationsUK Health Security Agency Book an Appointment Online. hm\J~#$H!WfD8hJ!=$%[t0VcweTM@B Option for HIPAA compliance. Your account is currently limited to {formLimit} forms. booster*, or other dose*, of the COVID-19 vaccine? These areas are [highlighted] below for your reference. width: 54, %%EOF
*If receiving anything but a first dose, please list date of last dose: If I am scheduling an appointment for a COVID-19 third dose, Integrate with 100+ apps. Is this person taking any medicine, like anticoagulants (blood thinners) or have a bleeding disorder? Learn more about membership with CDA. (Our apologies!) Copy this COVID-19 Vaccination Card Upload Form to your Jotform account. With the COVID-19 pandemic getting more and more serious every day, its important to support those whove been hit the hardest. This document provides general information related to the law but does not provide legal advice. Is medical consent required for LTC residents to receive a booster shot of Pfizer-BioNTech COVID-19 vaccine? I authorize the release of medical or other information necessary to process billing claims. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. They help us to know which pages are the most and least popular and see how visitors move around the site. Added open source and MS Word version of the adult consent form. PDF, 51.1 KB, 1 page. The risk of any vaccine causing serious harm, or death, is extremely small. Check back for updates, Note:If you need to schedule an appointment at this time slot for two (2) or more people, complete the form for one (primary) person, and additional patients will be added when you arrive, function SvgDhtupload2(props) { Upon your arrival, you may plan your grocery trips, find weekly savings, and even order select products online at
Use the COVID-19 booster tool to learn when you can get an updated (bivalent) booster to stay up to date with all recommended COVID-19 vaccines. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. If you have insurance questions, please call us at 515-961-1074. Author: New York State Department of Health Created Date: 20221118202434Z . Nursing homes are required by the Centers for Medicare and Medicaid Services (CMS) to monitor weekly COVID-19 vaccination data for residents and healthcare personnel through. COVID-19 vaccines can help keep you from getting seriously ill if you do get COVID-19. By assuming the risks involved, this helps relieve the establishment form any liabilities that may arise. The COVID-19 vaccination consent form letter templates are available in different software versions and can be downloaded and adapted to suit the needs of local healthcare teams. %PDF-1.7
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The COVID-19 Booster Declination Form is a template for you to provide to your employees that would like to decline receiving the COVID-19 booster for medial or religious reasons. You can review and change the way we collect information below. I voluntarily request and consent that a Publix Vaccine Provider administer the selected vaccine for which this appointment is being made ("Vaccine") to the patient . The demographic and vaccine administration information included in this form was verified and validated by a second clinician (other than the immunizer) at the immunization site to ensure. We have the Moderna COVID-19 BIVALENT Vaccine Available for all boosters. Vaccination is an essential public health measure for preventing the spread of illness during this continuing COVID-19 epidemic. A COVID-19 booster vaccine consent form is used by medical organizations to collect personal and medical information from patients who are interested in the COVID-19 booster vaccine. To expedite your service, please print the Immunization Consent Form that corresponds with your state, fill it out, and bring it to your neighborhood Publix Pharmacy. Document the person's refusal from receiving the COVID-19 vaccination. Easy to customize, share, and fill out on any device. Fully customizable with no coding. No coding is required. Is consent for a booster shot of Pfizer-BioNTech COVID-19 vaccine required if the vaccine is being administered by a different provider? Easy to customize and embed. Sacramento, CA 95814 Evidence about the safety and . Date of Birth: * / / Form Completed by: * Please type your name. Simply add your logo and customize the form to fit the way you want to communicate it with your patients. Just customize the form to receive the info you need then embed the form in your website, share it with a link, or have patients fill it out in person on your offices tablet or computer. Easy to customize, integrate, and share online. I have had a chance to ask questions which were answered to my satisfaction. Is consent required for the booster shot if consent was previously given for the Pfizer-BioNTech primary series? The immune response developed by the host or the continuation of the immunological response caused by vaccination is crucial since it might alter the epidemic's prognosis. https://www.cdc.gov/media/releases/2021/p0924-booster-recommendations-.html, COVID-19 Vaccine Access in Long-term Care Settings, Long-term Care Administrators and Managers: Options for Coordinating Access to COVID-19 Vaccines, COVID-19 Vaccines for Long-term Care Facility Residents, About mRNA Vaccines: Background Information for Healthcare Providers, National Center for Immunization and Respiratory Diseases, Use of COVID-19 Vaccines in the U.S.: Appendices, FAQs for the Interim Clinical Considerations, Myocarditis and Pericarditis Considerations, Jurisdictions: Vaccinating Older Adults and People with Disabilities, Vaccination Sites: Vaccinating Older Adults and People with Disabilities, Vaccinating Patients upon Discharge from Hospitals, Emergency Departments & Urgent Care Facilities, Vaccines for Children Program vs. CDC COVID-19 Vaccination Program, FAQs for Private & Public Healthcare Providers, Talking with Patients about COVID-19 Vaccination, Talking to Patients with Intellectual and Developmental Disabilities, How to Tailor COVID-19 Information to Your Audience, How to Address COVID-19 Vaccine Misinformation, Ways to Help Increase COVID-19 Vaccinations, COVID-19 Vaccination Program Operational Guidance, What to Consider When Planning to Operate a COVID-19 Vaccine Clinic, Using the COVID-Vac Tool to Assess COVID-19 Vaccine Clinic Staffing & Operations Needs, Considerations for Planning School-Located Vaccination Clinics, How Schools and ECE Programs Can Support Vaccination, Customizable Content for Vaccination Clinics, Best Practices for Schools and ECE Programs, Connecting with Federal Pharmacy Partners, Resources to Promote the COVID-19 Vaccine for Children & Teens, Information for Long-term Care Administrators & Managers, Vaccinating Dialysis Patients and Healthcare Personnel, What Public Health Jurisdictions and Dialysis Partners Need to Know, Supporting Jurisdictions in Enrolling Healthcare Providers, Vaccine Administration Management System (VAMS), Resources for Jurisdictions, Clinics, and Organizations, 12 COVID-19 Vaccination Strategies for Your Community, How to Engage the Arts to Build COVID-19 Vaccine Confidence, Strategies for Reaching People with Limited Access to COVID-19 Vaccines, U.S. Department of Health & Human Services. Individuals under the age of 18 are NOT eligible for Moderna COVID-19 vaccine. Vaccinator Signature: _____ * Use of this form is optional. ADHS COVID-19 Vaccine Consent Form . With the signature field, your participants can draw their signature in the same manner as how one would sign on a paper document. The coronavirus ( COVID-19) vaccination consent form and letter templates are available in different software versions and can be downloaded. 61 Colindale Avenue For patients to be vaccinated: The following questions will help us determine if there is any reason we should not give your child an inactivated injectable influenza vaccination today. No coding required. Easy to customize, share, and integrate. Get to know how people feel about the new COVID-19 vaccine with a custom online survey. Sign in approved COVID-19 vaccines'). I am of legal age and authorized to execute this consen t form or I am the parent/guardian of the minor patient. Well send you a link to a feedback form. COVID-19 Immunization Consent Form 1 Last updated 1/10/2022 SECTION 1: PATIENT INFORMATION PATIENT NAME: PATIENT DATE OF BIRTH: PARENT/LEGAL GUARDIAN/LEGALLY AUTHORIZED REPRESENTATIVE NAME (If the patient is under 18, or has . More information is available, Travel requirements to enter the United States are changing, starting November 8, 2021. and document the completeness and accuracy of all Immunization Records. COVID-19 Vaccines for Long-term Care Residents, Safe, Easy, Free, and Nearby COVID-19 Vaccination, Centers for Disease Control and Prevention. Use Jotforms drag-and-drop Form Builder to quickly add your appointment slots to the calendar widget, which automatically makes bookings unavailable once they have been booked by a previous patient a great way to avoid double-booking! Talk with the LTC staff about getting vaccinated on site. Prevent the spread of COVID-19 with a free Screening Checklist for Visitors and Employees. Collect signed COVID-19 vaccine consent forms online. Employee COVID-19 Self-Screening Questionnaire tracks the health condition of your employee and helps to take the precautionary measures to prevent the spreading of coronavirus in the workspace. Get this here in Jotform! No coding is required. Children aged between 5-11 who previously received a monovalent booster, Do not sell or share my personal information. Consent or assent for a COVID-19 vaccine is given by LTC residents (or people appointed to make medical decisions on their behalf called a medical proxy) and documented in their charts per the providers standard practice. to keep exploring our resource library. Updated November 18, 2022. Coronavirus (COVID-19) vaccination consent form and letter templates for adults who are able to consent. Collect data from any device. For COVID-19 vaccine only: Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies; Yes No: Don't know : . More information is available, Recommendations for Fully Vaccinated People, Children and teens ages 6 months-17 years, different recommendations for COVID-19 vaccines, Older adults and people with certain health conditions, stay up to date with all recommended COVID-19 vaccines, What to Expect after Your COVID-19 Vaccine, Frequently Asked Questions about COVID-19 Vaccination, Information about Medicare and COVID-19 Vaccine, Talking with Patients about COVID-19 Vaccination, National Center for Immunization and Respiratory Diseases (NCIRD), Possibility of COVID-19 Illness after Vaccination, Investigating Long-Term Effects of Myocarditis, How and Why CDC Measures Vaccine Effectiveness, Monitoring COVID-19 Cases, Hospitalizations, and Deaths by Vaccination Status, Monitoring COVID-19 Vaccine Effectiveness, U.S. Department of Health & Human Services.