Annex B: Practitioner authorisation sheet
AstraZeneca COVID-19 Vaccine (ChAdOx1-S [Recombinant]) Vaccine Protocol
Valid from: Expiry:
Before signing this Protocol, check that the document has had the necessary authorisations. Without these, this Protocol is not lawfully valid.
By signing this Protocol, you are indicating that you agree to its contents and that you will work within it.
Protocols do not remove inherent professional obligations or accountability.
It is the responsibility of each practitioner to practise only within the bounds of their own competence and any appropriate professional code of conduct.
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.
Person authorising on behalf of the 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.
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.
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