(General Edition Second Edition)

Recipient's name: gender: date of birth: year month disease introduction novel coronavirus (coronavirus pneumonia COVID-19-19) is a new acute respiratory infectious disease. The main clinical manifestations are fever, dry cough and fatigue, and a few patients are accompanied by symptoms such as nasal congestion, runny nose, sore throat, conjunctivitis, myalgia and diarrhea. Most patients have a good prognosis, and a few patients are critically ill. With the spread of the epidemic, it poses a serious threat to global public health. According to the current needs of prevention and control in COVID-19, novel coronavirus vaccination should be carried out for school-age population.

Effect of Vaccination This product can stimulate the body to produce immunity against novel coronavirus, and can be used to prevent diseases caused by novel coronavirus.

Inoculation contraindications See the product manual for the contraindications of inoculation. Usually, the taboos of vaccination include: (1) people who are allergic to vaccines or vaccine ingredients; (2) Suffering from acute diseases; (3) those who are in the acute episode of chronic diseases; (4) people who are having a fever; (5) pregnant women.

Adverse reactions after vaccination, local adverse reactions are mainly pain at the inoculation site, including local itching, swelling, induration, redness and swelling. General adverse reactions are mainly fatigue and weakness, including fever, muscle pain, headache, cough and diarrhea.

Precautions: Observe for 30 minutes after inoculation; If you feel unwell after vaccination, seek medical advice in time and report to the vaccination unit. Like other vaccines, vaccination with this vaccine may not have a 100% protective effect on all recipients. The above contents can be found in the vaccine instructions.

After investigation, diagnosis or appraisal, the compensation for abnormal reaction is concluded as abnormal reaction or abnormal reaction cannot be ruled out, and compensation shall be made in accordance with relevant regulations.

Please read the above contents carefully and truthfully provide the health status of the recipients and whether there are any vaccination taboos. If in doubt, please consult medical and health personnel.

The health status of the recipient

To be completed by the recipient/guardian.

Acute attack of fever, acute disease and chronic disease.

In the past, there have been allergies to vaccines or vaccine ingredients, as well as severe allergic reactions to vaccines.

Uncontrollable epilepsy, encephalopathy and other progressive nervous system diseases.

be pregnant

Severe chronic diseases

suckling period

Other cases

Yes or no

Yes or no

Yes or no

Yes or no

Yes or no

Yes or no

Yes or no

Understand the variety, function, contraindications, adverse reactions, on-site observation and other precautions of the vaccine, and truthfully provide the health status of the recipients and whether there are any contraindications for vaccination.

Beneficiary/guardian (signature, signature of minor guardian): Date: MM DD YY.

Relationship between guardian and recipient: mother, father and others (please specify)

Contact information of the guardian:

Legal Basis: Technical Guide for Vaccination in COVID-19 (First Edition) This guide is used by health departments and disease control institutions at all levels in COVID-19 to guide vaccination units to carry out vaccination work.