CoronaVac – Inactivated Vaccine (Vero Cell) (Sinovac)

(1)

(2)

Note: Please complete this form in BLOCK letters using black or blue pen and put a “” in appropriate boxes and *delete as appropriate.

 All vaccine recipients should bring the (1) ORIGINAL COPY of the relevant identity document on the day vaccination AND (2) Student handbook or student card with photo.

 Please read the (1) Vaccination Fact Sheet and (2) FAQs on the following websites:

(1) https://www.covidvaccine.gov.hk/pdf/COVID19VaccinationFactSheet_CoronaVac_ENG.pdf

(2) https://www.covidvaccine.gov.hk/pdf/FAQ_children_adolescents_ENG.pdf

Part 1. Personal Details of Vaccine Recipient (as indicated on identity document) Personal Information

School Name: ___________________________________________ Class: _________ Class No.: ________

Name: ,

(English) (surname) (given name)

(Chinese) (surname) (given name)

Date of Birth: __________/__________/__________ (DD/MM/YYYY) Gender: _________

Identity Document (Please put a “” in the box and fill in the document number as appropriate)

 If the vaccine recipient has Hong Kong Identity Card (HKIC), please fill in information of the HKIC



If the vaccine recipient does not have HK Identity card, please fill in the Hong Kong Birth Certificate Registration No.;

but if the vaccine recipient was not born in Hong Kong, please fill in the relevant identity document number

□ Hong Kong Identity Card No.:

Date of Issue: _____/_____/_______ (dd/mm/yyyy)

( )

HKIC Symbol:  A  C  R  U

□ Hong Kong Birth Certificate Registration No.: ( )

□

Hong Kong Re-entry Permit No. (Beginning with "RM" / "RS"):

Date of Issue: _____/_____/_______ (dd/mm/yyyy)

R

□

Hong Kong Birth Certificate Registration No.: HKSAR Document of Identity No. (Beginning with "D") : Date of Issue: _____/_____/_______ (dd/mm/yyyy)

D

□

Permit to Remain in HKSAR (ID 235B) - Birth Entry No.:

Permitted to remain until: _____/_____/_______ (dd/mm/yyyy)

( )

□

Non-Hong Kong Travel Documents No. (e.g. Foreign passports):

HKSAR Visa / Reference No.: - - ( )

□

Certificate issued by the Births Registry for adopted children–

No. of Entry: /

□

If the recipient is not the holder of the above documents,

please enclose a copy of other identity document. Document number: ___

CoronaVac – Inactivated Vaccine (Vero Cell) (Sinovac)

Consent Form for the COVID-19 Vaccination Programme

– Primary Schools and Kindergartens

Part 2: Consent to Administration of COVID-19 Vaccination

□ I consent to (a) the administration of COVID-19 Vaccination to my child / my ward * under the COVID- 19 Vaccination Programme (see particulars in Part 3); and (b) the access and use by the Department of Health and the relevant organisations collaborated with the Government (including the University of Hong Kong) of my child/ my ward’s * clinical data held by the Hospital Authority and the relevant private healthcare facilities and healthcare professionals for the purpose of continuously monitoring of the safety and clinical events associated with COVID-19 Vaccination by the Department of Health insofar as such access and use are necessary for the purpose.

Part 3: Particulars of COVID-19 Vaccination

Note: A consent form is required for each dose of vaccination

A. Type and Dose Sequence of COVID-19 vaccination

(Put a “” in the most appropriate box)

B. CoronaVac should not be given to persons with the following conditions If the vaccine recipient has the following condition(s), please ✓ in the

appropriate ☐. Vaccine Recipient has the

following condition(s):

 History of allergic reaction to CoronaVac or other inactivated vaccine, or any component of CoronaVac (active* or inactive* ingredients, or any material used in manufacturing process);

☐

 Previous severe allergic reactions to the vaccine (eg, acute

anaphylaxis, angioedema, dyspnea, etc.);

^☐

 Severe neurological conditions (eg, transverse myelitis, Guillain-

Barré syndrome, demyelinating diseases, etc.);

^☐

 Uncontrolled severe chronic diseases;

(Note: Common chronic diseases include diabetes, hypertension and coronary heart disease, etc. If your chronic disease is stable, you should receive the vaccine for protection because chronically-ill persons have a higher risk of serious illness or death from COVID-19 infection. If you are unsure about your condition, or if there is a recent change in your disease/

recent adjustment of drugs/ recent need for referral, etc, please discuss with your family doctor or attending doctor the appropriate time for vaccination.)

☐

* Including inactivated SARS-CoV-2 Virus (CZ02 strain), aluminium hydroxide, disodium hydrogen phosphate dodecahydrate, sodium dihydrogen phosphate monohydrate, and sodium chloride.

Part 4: Declaration and Signature

CoronaVac – Inactivated Vaccine (Vero Cell) (Sinovac)



1^st dose



2^nd dose



3^rd dose



4^th dose



Others, please specify: __________ dose

To be completed by parent / guardian

I have read and I understood the information in the Vaccination Fact Sheet for the COVID-19 vaccine particularised in Part 3, including contraindications (and possible adverse events) of COVID-19 vaccination, the vaccine product is authorised under the Prevention and Control of Disease (Use of Vaccines) Regulation

Additional information if the vaccine recipient is aged between 6 months and less than 3 years: I understand that the use of CoronaVac (Sinovac) Vaccine on children aged between 6 months and less than 3 years old is not listed in the approved package insert of the CoronaVac authorized under the Prevention and Control of Disease (Use of Vaccines) Regulation (Cap. 599K). This is an off-label use allowed in the Government programme under the Prevention and Control of Disease (Use of Vaccines) Regulation (Cap.599K) , having regard to the advice from panel(s) / committee(s) of experts appointed by the Government upon review of the current and anticipated epidemic situation, as well as the relevant efficacy and safety data available. The person who prescribes, dispenses or is responsible for the administering of the vaccine to my child / ward* acts in accordance with the Government’s direction in the Government programme.

I confirm that by signing underneath, I consent to (a) the administration of COVID-19 Vaccination to my child / my ward * under the COVID-19 Vaccination Programme (see particulars in Part 3); and (b) the access and use by the Department of Health and the relevant organisations collaborated with the Government (including the University of Hong Kong) of my child / my ward’s * clinical data held by the Hospital Authority and the relevant private healthcare facilities and healthcare professionals for the purpose of continuously monitoring of the safety and clinical events associated with COVID-19 Vaccination by the Department of Health insofar as such access and use are necessary for the purpose.

I declare the information provided in this form is correct.

I agree to provide my child / my ward’s* personal data in this form for the use by the Government for the purposes as set out in the “Statement of Purpose of Collection of Personal Data”. I understand that the Government may contact me to verify the information and the arrangement of the vaccination.

For Smart Identity Card holder: I agree to authorise the Healthcare Providers / public officers to read my child / my ward’s* personal data [limited to Hong Kong Identity Card No., Name (in English and Chinese), date of birth and date of issue of Hong Kong Identity Card] saved in the chip embodied in my/ my child / my ward’s* Smart Identity Card for the use by the Government for the purposes as set out in the “Statement of Purpose of Collection of Personal Data”.

This consent form shall be governed by and construed in accordance with the laws of Hong Kong Special Administrative Region and I shall irrevocably submit to the exclusive jurisdiction of the Courts of Hong Kong Special Administrative Region.

Signature of Parent / Guardian*:

Name of Parent / Guardian* (in English):

Relationship:

HKID/ Other Identity Document - Document Type and Document No. of Parent/ Guardian*:

Contact Telephone No.:

Date:

To be completed by Healthcare Provider

(Not required for Community Vaccination Centre)

1

^st

Dose

_______

Dose

eHS(S) Transaction No.

ONE TRANSACTION NUMBER ONLY

(if applicable)

T ______-____ _____-_____ T ______-____ _____-_____

Date of Vaccination Name of Doctor

Statement of Purpose of Collection of Personal Data

The provision of personal data is voluntary. If you do not provide sufficient information, you may not be able to receive vaccination.

Purpose of Collection

1. The personal data provided will be used by the Government for one or more of the following purposes:

(a) checking with relevant government departments and organisations on the status of receiving COVID-19 vaccine;

(b) informing relevant government bureaux or departments and organisations for arranging vaccination and follow up after the vaccination;

(c) for creation, processing and maintenance of an eHealth (Subsidies) account, and the administration and monitoring of the COVID-19 vaccination programme, including but not limited to a verification procedure by electronic means with the data kept by the Immigration Department;

(d) transferring to the Department of Health and relevant organisations collaborated with the Government (including the University of Hong Kong) forcontinuous monitoring of the safety and clinical events associated with COVID-19 Vaccination under the COVID-19 Vaccination Programme;

(e) for statistical and research purposes;

(f) preventing, protecting against, delaying or otherwise controlling the incidence or transmission of the COVID- 19 disease, including contact tracing; and

(g) any other legitimate purposes as may be required, authorised or permitted by law.

Classes of Transferees

2. The personal data you provided will be transferred to the Government and may also be disclosed by the Government

3. You have the right to request access to and correction of your personal data under sections 18 and 22 and principle 6, schedule 1 of the Personal Data (Privacy) Ordinance (Cap. 486). The Department of Health may impose a fee for complying with a data access request.

Enquiries

4. Enquiries concerning the personal data provided, including the request for access and correction, should be addressed to:

Executive Officer (Programme Management and Vaccination Division)

Address: Centre for Health Protection, Block A, 2/F, 147C Argyle Street, Kowloon Telephone No.: 2125 2045