Coronavirus (COVID-19) vaccine - Comirnaty® (mRNA Vaccine, Pfizer/BioNTech): national protocol

Annex B: Practitioner authorisation sheet

Comirnaty® (COVID-19 mRNA Vaccine, Pfizer/BioNTech) Protocol

Valid from:

Expiry:

Before signing this Protocol, check that the document has had the necessary authorisations in section 1 and 2. Without these, this Protocol is not lawfully valid.

Practitioner

I confirm that I have read and understood the content of this Protocol and that I am willing and competent to work to it within my professional code of conduct.

Name

Designation

Signature

Date

Person authorising on behalf of Provider

I confirm that the practitioners named above have declared themselves suitably trained and competent to work under this Protocol. I give authorisation on behalf of insert name of organisation for the above named health care professionals who have signed the Protocol to work under it.

Name

Designation

Signature

Date

Note to person authorising on behalf of Provider

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 those practitioners authorised to work under this Protocol.