Hepatitis B
CONSENT FORM
WHAT IS HEPATITIS B VIRUS?
HOW CAN A HBV INFECTION BE PREVENTED?
Hepatitis B virus (HBV) is found in blood, and bodily fluids. HBV can cause
serious liver damage, life-long infection, liver failure, and even death.
Many people with Hepatitis B do not know that they are
infected. How to prevent infection with HBV:
HOW IS HBV SPREAD?
1. Immunization.
HBV is spread through contact with infected blood and bodily fluids. This
can occur through:
2. Make sure all procedures such as tattooing, use clean,
sterile equipment.
• sharing personal items, such as toothbrushes, razors, nail files, and
nail clippers.
• sexual contact with an infected person.
• contact with non-sterile tools used in tattooing, body piercing, and
acupuncture.
• contact with infected blood in dirty needles used for injecting
drugs.
• an infected pregnant woman can pass HBV to her baby at birth.
It is important to know that HBV cannot be spread through water, food,
or by casual contact with others in places such as at home, at school, or
at work.
IS TREATMENT FOR HBV AVAILABLE?
There is no treatment available to completely cure an individual infected
with HBV and some individuals will become long-term carriers of the
disease. For those with chronic HBV infections, there are medications
available that decrease the amount of liver damage, but they do not
prevent the spread of the infection to other people.
Risk of Hepatitis B
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3. Don’t share personal items such as razors or toothbrushes.
WHO CAN RECEIVE HBV IMMUNIZATION?
Immunization is available at no cost for all Grade 7 students in
Ontario and is provided through school immunization clinics.
Immunization is also available for certain high-risk groups.
WHO SHOULD NOT GET THE HEPATITIS B
VACCINE?
• You have a history of severe reactions to vaccinations in
the past.
• If you have a fever or anything more serious than a minor
cold (delay immunization until you are well).
• You have an active neurological disorder such as GuillainBarre Syndrome.
• You have severe allergies to yeast, latex, aluminum, and
formaldehyde.
Risk of Immunization
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CONSENT FOR HEPATITIS B IMMUNIZATION
Student’s Name: Last _______________________________First _____________________
Date of Birth: yr __________ mm_________ day_________
Health Card #: __________________________________
School:_________________________ Room: _________
I HAVE READ THE INFORMATION ABOUT THE HEPATITIS B IMMUNIZATION. CHECK ONE:
YES, please immunize my child with two doses of Hepatitis B immunization.
NO, my child was previously immunized with Hepatitis B or Twinrix vaccine. Dates given:________________
Parent/Guardian (please print) _______________________________________ Date:__________________________
Signature:________________________________ Phone: _________________Email:________________________
FOR PUBLIC HEALTH USE ONLY:
Date/Time
(ie. 2016-Jun-06 0900)
Site
Dose #1
R
L
Dose #2
R
L
Lot # & Signature
Engerix
Recombivax HB
Engerix
Recombivax HB
COMMENTS:
This information is being collected under the authority of the Immunization of School Pupils Act, R.S.O. 1990, c.I.1 and the
Health Protection and Promotion Act, R.S.O. 1990, c.H.7 for the purpose of enabling the Medical Officer of Health for Leeds,
Grenville & Lanark to maintain a record of immunization and for the provision of statistical data to the Ministry of Health and
Long Term Care. This information will be retained, used, disclosed and disposed of in accordance with the Personal Health
Information Protection Act, 2004, S.O. 2004, c. 3. This information may be shared with organizations such as Cancer Care
Ontario for research and evaluation purposes. For more information, contact the Vaccine Preventable Diseases Program at the
Leeds, Grenville & Lanark District Health Unit at 1-800-660-5853.
For more information, contact the Health ACTION
Line 1-800-660-5853 or visit www.healthunit.org
3201b Jun 2016 Adapted with the permission of KFL&A Public Health
Leeds, Grenville & Lanark District
HEALTH UNIT
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