AstraZeneca COVID-19 Vaccine (ChAdOx1-S [Recombinant]) Vaccine National Protocol

Annex C: Clinical Supervision sheet

AstraZeneca COVID-19 Vaccine (ChAdOx1-S [Recombinant]) Vaccine Protocol v02.1 Valid from: DDDDDD Expiry: DDDDDD

This sheet must record the name of the clinical supervisor taking responsibility and all of the people working under different activity stages of the protocol.

Activity stages of the vaccination pathway under this protocol:

Stage 1:

a. Assessment of the individual presenting for vaccination

b. Provide information and obtain informed consent

c. Provide advice to the individual

Registered Healthcare Professionals Only

Stage 2:

• Vaccine Preparation

Registered Healthcare Professionals, non-registered professionals or non-registered Armed Forces staff

Stage 3:

• Vaccine Administration

Registered Healthcare Professionals, non-registered professionals or non-registered Armed Forces staff

Stage 4:

• Record Keeping

Registered Healthcare Professionals, non-registered professionals or non-registered Armed Forces staff

The clinical supervisor has ultimate responsibility for safe care being provided under the terms of the protocol. Persons working under the protocol may be supported by additional registered healthcare professionals, but the clinical supervisor retains responsibility.

Before signing this Protocol, check that the document has had the necessary authorisations. Without these, this Protocol is not lawfully valid.

Clinical Supervisor

Practitioner(s) and Activity Stages

Note to Clinical Supervisor

Score through unused rows in the list of practitioners to prevent practitioner additions post managerial authorisation.

This authorisation sheet should be retained to serve as a record of clinical supervision arrangements for those working under this Protocol.