Is English your family's main language spoken at home? No. Yes ... R. YES, I Consent. CONSENT for Vaccination: parent/le
Gold Coast Health | Public Health Unit
School Immunisation Program CONSENT FORM YEAR 7
School
Class
Student Details Surname Given Names Date of Birth
/
/
Gender
Male
Medicare No.
Female
Reference No. on card
Home Address
State
Suburb
Yes
Does your child identify as either Aboriginal or Torres Strait Islander? If yes, please select one of the following:
Aboriginal
Is English your family's main language spoken at home?
No
Torres Strait Islander (TSI) Yes
Postcode
Both Aboriginal and TSI
No
If no, what language is spoken?
Parent/Legal Guardian Details Relationship to student listed on this form
Parent
Legal Guardian
Surname Given Names
Mobile
Phone (daytime) Email
Pre Vaccination Checklist (please tick any box that applies to your child) has previously had a reaction to a vaccine
has a known medical condition
faints when given an injection
can be highly anxious about vaccination
has severe allergies
has special needs
has received any vaccine recently
is pregnant
Please provide details below if you have ticked any of the above boxes.
Prior to administering the vaccine(s), the nurse immuniser will ask the student if the information above needs to be updated. Please inform us of any changes as it may be some weeks between when you provide this information and your child receiving the vaccine(s). Vaccination Consent Form / v2017
Gold Coast Health | Public Health Unit
School Immunisation Program CONSENT FORM YEAR 7
CONSENT for Vaccination: parent/legal guardian to read and sign I am authorised as the parent or legal guardian of the listed child to give consent for the child to be vaccinated. I have read and I understand the information given to me about human papillomavirus vaccine and diphtheria-tetanuspertussis vaccine including risks and side effects. I have been given the opportunity to discuss the risks and benefits of vaccination with my doctor or by telephoning 13 HEALTH (13 43 25 84). I understand that Queensland Health will record immunisation details, forward them to the Australian Immunisation Register and Vaccine monitoring service for the purpose of clinical follow up or disease prevention, control and monitoring. I understand that I can change my consent at any time. If I wish to change consent: - up to 2 business days before immunisation takes place at the school, I understand I need to do so by making a written request via email to Gold Coast Public Health Unit at
[email protected]. - within 2 business days of immunisation, I understand that I need to send a signed written request of changes with my child to take to the school immunisation team or alternatively I need to meet in person with the school immunisation team to confirm that changes to my child's consent have been received.
For EACH vaccine please select either Yes or No Human Papillomavirus (HPV) vaccine (3 doses) YES, I Consent
Parent/legal guardian signature:_________________________________
No, I Do Not Consent because:
Date:
my child will recieve vaccine from the family doctor
/
/
my child has already had HPV vaccination I do not want my child to be vaccinated
Diphtheria-Tetanus-Pertussis (whooping cough) dTpa vaccine (1 dose) YES, I Consent
Parent/legal guardian signature:_________________________________
No, I Do Not Consent because:
Date:
my child will recieve vaccine from the family doctor
/
/
my child has already had dTpa vaccination I do not want my child to be vaccinated Office Use Only Vaccine
Pre Vx check completed
Arm
Vaccine Batch No.
HPV1
Y
N
R
L
dTpa
Y
N
R
L
Y
N
R
L
Y
N
R
L
Notes:
HPV2
Notes:
HPV3
Notes:
Vaccination Consent Form / v2017
Date Given dd/mm/yy
Time Vaccinated
Immuniser Name and Signature
