Tualatin Valley Fire & Rescue Covid-19 Vac ~ IG214004 ~ Covid-19 Vaccination TVFiD
TERMS OF SERVICE
Tualatin Valley Tualatin Valley Fire &Rescue
Fire & Rescue COVID-19 Vaccination
These Terms of Service("Terms")apply to Tualatin Valley Fire&Rescue's ("TVF&R")provision of the
COVID-19 vaccine to Eligible Recipients of ("Agency").
These Terms may be updated or amended by TVF&R from time to time at TVF&R's sole discretion.
1. TVF&R's COVID-19 Vaccination Services("Vaccination Services"):
a. COVID-19 Informational Materials. At no cost to Agency or any of Agency's Eligible
Recipients, TVF&R will provide Agency with training materials, informed consent forms, and
other related templates and forms("Informational Materials")designed to educate Eligible
Recipients about the two-dose COVID-19 vaccine and facilitate their informed consent to receive
the two-dose COVID-19 vaccine.
b. Designation of Program Contact. TVF&R will designate a Vaccine Scheduling Coordinator to
oversee the Vaccination Services and serve as Agency's single point of contact to schedule
Vaccination Services and receive reports of Adverse Events.
c. Vaccine Point of Distribution Events. TVF&R will coordinate vaccine Point of Distribution
("POD")events at various locations, dates,times, and capacities to be determined by TVF&R at
its sole discretion.
d. Capacity. Due to a limited supply of COVID-19 vaccine, TVF&R does not, and cannot guarantee
that all Eligible Recipients will receive the COVID-19 vaccine as scheduled. If necessary,
TVF&R will coordinate with Agency to reschedule any Eligible Recipient who does not receive
the first or second dose of the COVID-19 vaccine during their scheduled vaccine POD event.
e. Administration of COVID-19 Vaccine. The COVID-19 vaccine is a suspension for intramuscular
injection administered as a series of two doses, approximately one month apart. At no cost to
Agency or any of Agency's Eligible Recipients, TVF&R will administer COVID-19 vaccine to
Eligible Recipients of the Agency who have: (i)given their written informed consent to receive
the vaccine;and(ii)passed TVF&R's COVID-19 pre-screening. TVF&R reserves the right to
refuse Vaccination Services to any Eligible Recipient who withholds their written informed
consent or fails to pass TVF&R's pre-screening procedures.TVF&R will administer the
vaccine in accordance with the terms and conditions of the Oregon Health Authority's COVID-19
Vaccination Program Provider Agreement,as it may be amended from time to time. TVF&R will
also provide a completed COVID-19 vaccination record card to every COVID-19 vaccine
recipient,the adult caregiver accompanying the recipient, or other legal representative. Eligible
Recipients who receive the first dose of the COVID-19 vaccine must provide the vaccination
record card when they return to receive their second dose of the COVID-19 vaccine.
f. Adverse Event Reporting. TVF&R will report any known Adverse Event following vaccination
of an Agency's Eligible Recipient to the Vaccine Adverse Event Reporting System(VAERS).
2. Agency Responsibilities:
a. Designation of Agency Liaison. Agency shall name a single point of contact to act as Agency
Liaison and provide the name,phone number, and e-mail address of its Agency Liaison to the
TVF&R Vaccine Scheduling Coordinator via e-mail at Vaccine(a),tvfr.com before scheduling
Vaccination Services. The Agency Liaison shall:
1. Designate persons associated with the Agency to receive a COVID-19 vaccine("Eligible
Recipients");
COVID-19 Vaccination Teams of Service Page 1 of 3 Last Updated: 1/4/2021
2. Select Eligible Recipients within the authorized vaccine phase in compliance with the
most current guidance from the Oregon Health Authority("OHA");
3. Provide the Vaccine Scheduling Coordinator with a completed External Agency's Roster
of Eligible Recipients form using the template provided by TVF&R,which includes each
Eligible Recipient's name, date of birth, contact number,and e-mail address. TVF&R
reserves the right to limit, in its sole discretion,the number of Eligible Recipients from
the Agency to be scheduled at each vaccine POD event;
4. Notify each Eligible Recipient of the date,time, and location of their first and second
scheduled vaccine POD event;
5. Inform each Eligible Recipient that the COVID-19 vaccine is administered as a series of
two doses, approximately one month apart;
6. Inform each Eligible Recipient of the requirement to sign a COVID-19 Vaccine Informed
Consent Form prior to receiving each dose of the COVID-19 vaccine;
7. Inform each Eligible Recipient of the requirement to provide their vaccination record
card when they return to receive their second dose of the COVID-19 vaccine;and
8. Complete and submit by e-mail at Vaccine(F�tvfr.com all forms, documents,and rosters
that may be required by the Vaccine Scheduling Coordinator. Vaccination Services will
not be scheduled until all required forms, documents, and rosters have been
received and verified by the Vaccine Scheduling Coordinator as complete.
b. COVID-19 Informational Materials and Informed Consent.
i. Agency shall deliver Informational Materials to all Eligible Recipients within 24 hours of
scheduling the Eligible Recipient to attend a first or second COVID-19 vaccine POD event.
ii. Agency shall require each Eligible Recipient to review all Informational Materials before
attending a vaccine POD event.
iii. Agency shall provide each Eligible Recipient with a copy of the COVID-19 Vaccine
Informed Consent form and related materials for review prior to the Eligible Recipient's
scheduled vaccine POD event. Eligible recipients will be required to sign a COVID-19
Vaccine Informed Consent Form at their scheduled vaccine POD events prior to receiving
each dose of the COVID-19 vaccine.
iv. Agency shall reconfirm distribution of the Informational Materials to all Eligible Recipients
prior to administration of the second dose of the COVID-19 vaccine.
c. Use of Facilities and Logistical Support.
i. At no cost to TVF&R,Agency shall provide facilities(e.g.,parking lot,restrooms),
equipment(e.g., chairs and tables), and personnel as needed to support vaccine POD events.
ii. For contact tracing and second dose tracking purposes,Agency shall provide the Vaccine
Scheduling Coordinator with a roster of all personnel(including contact information)who
attended a vaccine POD event. If any of Agency's personnel are presumed or confirmed
positive for the SARS-CoV-2 virus or COVID-19 disease within 14 days after attending a
vaccine POD event,Agency shall notify the Vaccine Scheduling Coordinator as soon as
reasonably possible, and no later than 24 hours from discovery.
iii. Agency shall track which of their Eligible Recipients received the COVID-19 vaccine at their
scheduled vaccine POD events and which Eligible Recipients did not. If an Eligible Recipient
did not receive the COVID-19 vaccine as scheduled,Agency is responsible for following up
with the Vaccine Scheduling Coordinator to reschedule the Eligible Recipient for future
vaccine POD events.
d. Notification of Adverse Events.
i. Agency shall name a single point of contact to receive reports of all COVID-19 vaccination
side effects from the Agency's Eligible Recipients("Notification Liaison")and provide the
name,phone number, and e-mail address of its Notification Liaison to TVF&R before
COVID-19 Vaccination Tenns of Service Page 2 of 3 Last Updated: 1/4/2021
attempting to schedule COVID-19 Vaccination Services. Agency may,but is not required to,
designate the same person to serve as both its Agency Liaison and Notification Liaison.
ii. Agency shall direct all Eligible Recipients to immediately call 911 if they experience any of
the following severe allergic reactions or side effects:trouble breathing; lightheadedness;
wheezing;hives;swelling of the lips,tongue,or throat; anxiety; a fast heartbeat; a rash all
over the body; dizziness; anNor weakness("Adverse Events").
iii. Agency shall direct all Eligible Recipients to contact Agency's Notification Liaison to report
all side effects,no matter how severe or minor, as soon as reasonably possible.
iv. The Notification Liaison shall report to TVF&R any Adverse Event experienced by any of
the Agency's Eligible Recipients within 24 hours of discovering the Adverse Event. The
report shall be made by calling the Agency's TVF&R Vaccine Scheduling Coordinator and
include the name of the Eligible Recipient and a list of all Adverse Events experienced.
v. Eligible Recipients may experience lesser symptoms such as local swelling,redness,pain,or
lymph node enlargement or tenderness. These are not Adverse Events and do not need to be
reported to TVF&R_
e. Indemnity.Without waiver of any limitation of liability or immunity granted to TVF&R under
the PREP Act or any other relevant federal or state law,Agency shall,to the fullest extent
permitted by law, fully indemnify,defend, and save, and hold harmless TVF&R,its officers,
board members, agents, employees,volunteers, affiliates,and all other persons acting on behalf of
TVF&R, from and against any and all claims, demands, suits,actions,damages, losses, costs, and
expenses, direct and indirect or consequential of any nature whatsoever, including reasonable
attorneys' fees,and any other costs of defense, settlement payments,and court costs, and liability
of personal injuries(including death),property loss,and all other legally cognizable harm caused
by,arising from,in whole or in part or in connection with,any act or omission involving the
provision Vaccination Services by TVF&R to any Eligible Recipient designated by the Agency.
The duty of defense shall arise immediately upon assertion of any claim that may be covered by
this indemnification provision, and,to the fullest extent allowed by law, shall be independent of
any duty of indemnification.
SIGNATURES:
These Terms of S ervice are acknowledged and accepted as evidenced by the signature below:
Agency:
By Authorized Head of Agency:
sib
Name-
Date_
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