Annex B: Practitioner authorisation sheet
COVID-19 Vaccine Moderna 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.
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.
Person authorising on behalf of Provider
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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