영 어	Consent Form for COVID-19 Vaccination and Personal Information Use and Collection (for foreigners)

▪ WHO IS ELIGIBLE: Foreigners aged 75 years or older (born before December 31, 1946) who are long-term residents in Korea (longer than 90 days)

▪ VACCINATION LOCATION: COVID-19 vaccination centers by district (free vaccination)

- If you have difficulty in going out or moving or are concerned about worsening the underlying disease while moving, it is difficult to get vaccinated at the COVID-19 vaccination center. However, even if it is difficult to move, you can get vaccinated if you visit the vaccination center with a guardian.

▪ Would you like to visit the COVID-19 vaccination center to get vaccinated? ☐ Yes  ☐ No

※ If you marked ‘No,’ you may be notified of other ways of vaccination.

▪ Long-term residents who do not have a foreigner registration number and those who are exempt from foreigner registration (Article 31 (1) of the Immigration Act) can apply for vaccination at the local (Eup/Myeong/Dong) Community Center after receiving a temporary administration number from a public health center. (You will need to bring your passport of ID.)

▪ Personal information such as foreigner registration number is collected in accordance with Article 33-4 of the Infectious Disease Control and Prevention Act, and Article 21-2 and Article 32-3 of the Enforcement Decree of the Infectious Disease Control and Prevention Act. Additional items collected are as follows:

▪ Purpose of collection and use of personal information: To notify information related to the second injection, abnormal reactions after vaccination, etc.

▪ Items to be collected and used: Name, foreigner registration number and contact number (home or mobile)

▪ Retention/Use period of personal information: 5 years

1. I hereby agree to the preliminary confirmation of the COVID-19 vaccination records through the COVID-19 Vaccination Management System before the procedure.

※ If you do not agree, it may lead to unnecessary or cross vaccinations.

☐ I agree

☐ I do not agree

2. How would you be notified of your COVID-19 vaccination date and time? (Select only one)

※ If you do not have a cell phone, you can contact your local community center for guidance.

☐ Naver app

☐ KakaoTalk (KaTok)

☐ Toss

☐ Text message

☐ I don’t want to receive notifications

3. Personal information

Name		Foreigner Registration Number (Temporary administration number)	-
Contact Number	(home) (mobile)

I hereby confirm that I thoroughly understood the content of this consent of personal information collection, use and provision and filled out the form.

Date (MM/DD/YYYY):
Name:                             (Seal or Signature)
(Name of guardian:                , Relation to applicant:                  )