Preventative Health


Pfizer COVID-19 Vaccine EUA Fact Sheets

Pfizer COVID-19 Vaccine EUA Fact Sheet For Recipients 02/21
Pfizer COVID-19 Vaccine EUA Facts 1.25
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Pfizer COVID-19 Vacuna EUA Hoja informativa para destinatarios 02/21
Pfizer COVID-19 Vaccine EUA Facts_s.pdf
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接受者和护理者须知 辉瑞-BioNTech2019 新冠肺炎疫苗用于 16 岁及以上人群的紧急使用授权 02/21
Pfizer COVID-19 Vaccine EUA Facts_c.pdf
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COVID-19 Pre-Vaccination Screening Forms

CDC COVID-19 Pre-vaccination screening form
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Formulario de detección previa a la vacunación COVID-19 de los CDC
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Stacy Medial Center will begin offering COVID-19 vaccinations on-site at the workplace for employees working within Vernon City Limits. When sufficient amounts of vaccine from the Los Angeles County Department of Health become available we will expand our region of service beyond Vernon City limits. 


If you are interested in vaccinating your employees please follow the instructions below:




Attn: Freddie Agyin, MS, REHS


Subject: Pre-order COVID-19 Vaccinations

 a: Name of Employer

 b: Business Address

 c: Location where employee(s) work

 d: Total number of employees age 65 and older

 e: Total number of employees age 65 and older desiring COVID-19      vaccination

 f: Telephone No.

 g: Name of contact


2: You will be contacted upon receipt of this letter of interest and your company will be prioritized in the vaccine queue per LAC guidelines.


3: You will be contacted at least 5 working days prior to scheduling vaccinations at your site. You will be required to distribute COVID-19 Vaccine EUA fact Sheets and COVID-19 Pre-vaccination screening forms to employees.  Following collection of completed COVID-19 Pre-vaccination screening forms from employees, you will login to our vaccine scheduling portal and pre-register each of your employees desiring vaccination, PRINT the appointment / consent form for each employee.


4: The day prior to vaccination we ask that you distribute the Vaccine appointment / consent from to each employee that commits to vaccination and report the number of doses required to Freddie Agyin, MS, REHS


5: On the day of vaccination we request that you dispatch 5 employees to the vaccination station every 15 minutes. The employees will be required to follow social distancing rules as they line up for vaccination.(It is important that we maintain the planned vaccination pace as the mixed vaccine is labile  and has a short shelf life). 


6: Following vaccination each employee will be asked to remain sitting in the post vaccination observation area for 15 minutes (30 minutes if they are at increased risk for anaphylaxis) prior to release back to their workstation.


7: The employee will automatically be rescheduled for their second dose of vaccine and the employees record of vaccination will automatically be filed with CAIR.


8: Site requirements:

  • Room to accommodate a Mercedes Sprinter Van
  • Room to accommodate a 10' x 15' tent
  • Room to accommodate a 7 fold-up chairs
  • 115V 15A outlet / extension cord

                         Click To Access Vaccination Scheduling Portal

This poster educates vaccine recipients on how to use their smart phone to report any unusual side effects they may experience following COVID-19 vaccination.
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V-Safe-Poster Spanish
This poster educates vaccine recipients on how to use their smart phone to report any unusual side effects they may experience following COVID-19 vaccination.
Adobe Acrobat Document 225.3 KB
V-Safe-Poster Chinese
This poster educates vaccine recipients on how to use their smart phone to report any unusual side effects they may experience following COVID-19 vaccination.
Adobe Acrobat Document 294.4 KB


The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). 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. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.

I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requires two doses, I will need to be administered (given) two doses of this vaccine in order for it to be effective. I have had a chance to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described.
I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.