TEAR OFF AND RETURN THIS SECTION TO SCHOOL
DO NOT PHOTOCOPY THIS SECTION
URN
Office Use Only
Year 7
ACT School Immunisation Program 2017
Consent Card for Diphtheria, Tetanus, Pertussis (whooping cough),
Varicella (chickenpox) & Human Papillomavirus (HPV) Vaccinations
It is important
that ALL cards
are returned to
school even if the
student is not being
vaccinated.
This assists in monitoring
the level of protection
against these diseases
as well as assisting with
the control of infectious
diseases in the ACT.
What if the student has
recently received a Tetanus
containing vaccine because
of an injury?
ADT Booster (Adsorbed
Diphtheria and Tetanus) vaccine
given after an injury does
not protect against Pertussis
(whooping cough).
Therefore it is recommended and
safe for the student to receive the
Diphtheria, Tetanus and Pertussis
(whooping cough) vaccine.
PLEASE PRINT CLEARLY IN BLACK INK
WHEN COMPLETING THIS FORM
Prior to administering the vaccine, the nurse will ask the student if this
information needs to be updated.
Family Name:...............................................................................................................................
Please tick the appropriate box(es) if the student is to be vaccinated:-
Given Name(s):...........................................................................................................................
Date of Birth:.................. /................/................. Age:......................
Is your child of Aboriginal or Torres Strait Islander origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Male
Female
Postal Address:...........................................................................................................................
..................................................................................... Postcode:...............................................
Medicare number
Ref no next to student’s name
Name of School:...............................................................................................................
Class & Year:.................................................................................................................................
Contact Details of Person Completing Form
Given Name(s):...........................................................................................................................
........................................................................
Relationship to student:
Parent
Legal Guardian
Best Daytime Contact Phone Number(s): 1..............................................................
2.............................................................
Page 1
has ever fainted when given
an injection
has a disease which lowers
immunity or lives with
someone who has lowered
immunity (e.g. leukaemia,
cancer, HIV/AIDS)
is having treatment which
lowers immunity (e.g. oral
steroid medications such as
cortisone and prednisone,
radiotherapy, chemotherapy)
has received a vaccine in the
last 4 weeks
has had an injection of
immunoglobulin or received
any blood products or had
a whole blood transfusion in
the past year
has any severe allergies
has a Severe Allergy/
Anaphylaxis Care Plan
has previously had a reaction
to a vaccine
is pregnant
has a medical condition (e.g.
epilepsy, asthma, diabetes,
including previous GuillianBarre syndrome)
If you have ticked any box above, please describe:.................................................
Family Name:...............................................................................................................................
........................................................................
If you are not consenting to vaccination, please go to Section C.
Section A - Student Details
OFFICE USE ONLY
........................................................................
Section B - Pre-Vaccination Checklist
............................................................................................................................................................
Parent/Legal Guardians please read the following
before completing consent form overleaf
I have read and understood the information given to me on the Year 7 Parent/
Guardian Information Sheet regarding immunisation including the risk of the
vaccination and the risk of not being vaccinated against Diphtheria, Tetanus &
Pertussis (whooping cough), Varicella (chickenpox) and Human Papillomavirus
(HPV). I understand that I can contact my School Immunisation Program provider
or the Health Protection Service, Immunisation Unit, to discuss these risks and
benefits. I understand that I can withdraw consent at any time before vaccination
takes place or during the course of the program. I understand the immunisation
provider will forward HPV vaccination details for all students to the National HPV
Vaccination Program Register unless I request my son/daughter details not to be
included on the register. Vaccination information may be shared with your child’s
treating team e.g. GP. If you require any further information please contact the
Health Protection Service, Immunisation Unit on 62052300.
Please Turn Over •
Section C - Parent/Legal Guardian to complete boxes 1, 2 & 3
Box 1 - All Students
Box 2 - All Students
Box 3 - All Students
Diphtheria, Tetanus and
Pertussis (whooping cough) vaccine
Varicella (chickenpox) vaccine
Human Papillomavirus (HPV) vaccine
The combined Diphtheria, Tetanus and Pertussis vaccine is a
BOOSTER VACCINE following a course given in early childhood.
Recommended for all students who have not had the chickenpox
vaccine, including those that have previously had the disease.
Yes I consent.
Yes I consent.
I have read the information sheet and consent for this
student to receive a single dose of the Diphtheria,
Tetanus and Pertussis (whooping cough) vaccine.
Yes I consent.
I have read the information sheet and consent for this
student to receive a single dose of the Varicella
(chickenpox) vaccination.
I have read the information sheet and consent for this
student to receive 3 doses of the Human Papillomavirus
(HPV) vaccination.
Signature of Parent/Legal Guardian:
Signature of Parent/Legal Guardian:
Signature of Parent/Legal Guardian:
..................................................................Date:........./......../........
..................................................................Date:........./......../........
..................................................................Date:........./......../........
No I do not consent.
No I do not consent.
No I do not consent.
After reading the information provided I do not wish to
have this student immunised with the Diphtheria, Tetanus
and Pertussis (whooping cough) vaccine at this time.
After reading the information provided I do not wish to
have this student immunised with the Varicella (chicken
pox) vaccine at this time.
Or
After reading the information provided I do not wish
to have this student immunised with the Human
Papillomavirus (HPV) vaccine at this time.
Or
This student has already received this vaccine and
therefore does not need the Diphtheria, Tetanus and
Pertussis (whooping cough) vaccine.
Or
This student has already received this vaccine, therefore
does not need the Varicella vaccine.
This student has already received three doses of
this vaccine therefore does not need the Human
Papillomavirus (HPV) vaccine.
Signature of Parent/Legal Guardian:
Signature of Parent/Legal Guardian:
Signature of Parent/Legal Guardian:
..................................................................Date:........./......../........
..................................................................Date:........./......../........
..................................................................Date:........./......../........
OFFICE USE ONLY
Page 2
Office Use Only
Diphtheria, Tetanus &
Pertussis
Varicella
HPV Dose 1
HPV Dose 2
HPV Dose 3
.....................................................................
Date:...........................................................
Date:...........................................................
Date:...........................................................
Date:...........................................................
Date:...........................................................
Batch Number:
Batch Number:
Batch Number:
Batch Number:
Batch Number:
......................................................................
......................................................................
......................................................................
......................................................................
......................................................................
.....................................................................
Site:
Site:
Site:
Site:
Site:
.....................................................................
Given By:..................................................
.....................................................................
Left Arm
Right Arm
Left Arm
Right Arm
Given By:..................................................
Left Arm
Right Arm
Given By:..................................................
Left Arm
Right Arm
Given By:..................................................
Left Arm
Right Arm
Given By:..................................................
TEAR OFF AND KEEP THIS SECTION
Year 7
ACT School Immunisation Program 2017
Parent/Guardian Information Sheet for Diphtheria, Tetanus,
Pertussis (whooping cough), Varicella (chickenpox) & Human Papillomavirus (HPV) Vaccinations
Nurses providing the
FREE ACT Health School
Immunisation Program
will be visiting your
child’s school soon.
Please read the
information provided
before completing
the Consent Card.
It is important that you
complete the Consent
Card accompanying this
Information Sheet and
return it to the school
even if you DO NOT
consent for the student
to be vaccinated.
Tear off and keep
this Parent/Guardian
Information Sheet for
future reference.
Page 3
Are vaccines safe?
• For most people vaccines are safe and do not cause serious
adverse reactions.
What if a student whose parent/legal guardian
has consented for vaccination is absent, unwell
or refuses the vaccination?
• At the end of the year you will receive a letter advising
you of any missed vaccines.
• Before a vaccine or any medication can be used in Australia,
it must be licensed by the Therapeutic Goods Administration
(TGA). The TGA makes sure that each vaccine is assessed
for safety and effectiveness based on scientific evidence
(clinical trials) before it is available to the community.
• Vaccines and all reported side effects continue to be
assessed and monitored by independent medical experts.
• Most vaccines can cause mild reactions. These are usually
short lasting, and do not require special treatment.
• As with any medication, very rarely an individual
may experience an anaphylactic reaction. The school
immunisation nurse is trained to recognise and manage any
immediate severe reactions which generally occur within
the first 15 minutes after receiving a vaccine. All students are
monitored closely for 15 minutes after their vaccination.
• All serious or unexpected reactions should be reported
to the Health Protection Service, Immunisation Unit, who
can provide you with information and advice on future
vaccinations and discuss any concerns you may have.
If you have any questions about this information, please
contact the Health Protection Service, Immunisation Unit on
02 6205 2300.
Note: It may take some weeks before the school
immunisation providers visit the school to vaccinate the
students. It is your responsibility to advise the School
Health Team (6205 2086) prior to or on the day of
immunisation of any change in the information on the
Consent Card and in particular, the student’s medical
condition.
• These missed vaccines will be available from the
1st December 2017 from your GP.
• These vaccines remain FREE for year 7 students until
the end of 2018.
What if a student is not taking part in the
school immunisation program?
• You will be able to access these vaccines FREE from your
GP from 1st December 2017 until the end of 2018.
It is advisable to inform your doctor of any
updates to the student’s vaccination status.
Where can I get more information?
Health Protection Service, Immunisation Unit:
Monday to Friday: 9am - 4.30pm
Phone: 02 6205 2300 Website: www.health.act.gov.au
School Immunisation Program - 6205 2086
www.health.act.gov.au/immunisation - click on High School
Immunisation Program
For more information on the ‘No Jab, No Pay’ Commonwealth
Government Policy see http://www.humanservices.gov.au/
customer/subjects/immunising-your-children or call 6205 2300
If English is not your first language and you require the
Translating and Interpreting Service (TIS) - Please call
13 14 50. Or visit www.health.vic.gov.au/immunisation/
factsheets.htm
Year 7 - ACT School Immunisation Program 2017
Parent/Guardian Information Sheet for Diphtheria, Tetanus, Pertussis (whooping cough), Varicella (chickenpox) & Human Papillomavirus (HPV)
Diphtheria
Pertussis
(whooping cough)
Varicella (chickenpox)
Human Papillomavirus (HPV)
Protection against HPV related cancers and
disease HPV is the name for a group of viruses
that affects both females and males. Some of
these viruses may cause genital warts and lead
to some cancers in both females and males.
An acute infectious illness
caused by bacteria that infects
the mouth, nose and throat.
A highly contagious respiratory
disease.
A highly contagious disease caused by the varicella-zoster
virus.
Spread by coughing and
sneezing from an infected
person for up to 4 weeks or
direct contact with skin lesions
or objects/articles soiled by
infected persons.
Spread by bacteria in respiratory
droplets through coughing
and sneezing. Adolescents and
adults can pass the disease on to
babies who are too young to be
immunised.
Spread by airborne droplets or through direct contact with
the fluid in the blisters of the rash.
Symptoms may include sore
throat, fever, hoarseness and
difficulty breathing/swallowing.
Complications include heart
and nervous system conditions
which may cause death.
Tetanus
Caused by a toxin produced
by a bacteria which is found in
soil, dust and manure.
Contracted through a cut
or wound which becomes
contaminated by the bacteria.
Symptoms may cause painful
muscle spasms, convulsions
and lock jaw.
Complications include heart
attack (cardiac arrest),
pneumonia, blood clot in the
lung (pulmonary emboli) and
death.
Symptoms may include runny
nose, sore watery red eyes and
fever. It then progresses to a
severe cough that may last for
months, where the person may
gasp for air causing a ‘whooping’
sound and may have severe
coughing spasms followed by
gagging or vomiting.
Complications include
pneumonia, convulsions and brain
damage. About one in 120 babies
less than 6 months of age die
from complications of whooping
cough who have the disease.
IMPORTANT
Protection against whooping
cough both from the disease and
the vaccine decreases over time.
Therefore a BOOSTER DOSE
is recommended to reduce the
incidence of whooping cough in
the community.
Symptoms include fever, feeling unwell followed by a rash
that turns into red spots and blisters. The blisters may
appear on the trunk, face and other parts of the body.
Complications include bacterial skin infections (resulting
in scarring), lung infection, brain damage and occasionally
death. If a pregnant woman has chickenpox there is a small
risk of harm to the unborn baby. Chickenpox can also lead
to shingles (herpes zoster) later in life.
Chickenpox vaccine is recommended for all students who
have not had the chickenpox vaccine, including those that
have previously had the disease.
• Can reduce the chance of contracting chickenpox by
85% or from experiencing severe chickenpox by 98%.
• Contains a small amount of the live virus at a reduced
strength and a small amount of the antibiotic, neomycin.
Common side effects of the Varicella vaccine include fever,
soreness, redness, swelling and a small temporary lump
at the injection site. Less commonly a small number of
chickenpox like spots may occur, usually at the injection
site and sometimes on other parts of the body between
five and 26 days after vaccination and last for less than one
week.
Please consult your doctor:
• If your child develops a generalised rash;
• If you have any concerns.
Common side effects of the Diphtheria, Tetanus & Pertussis vaccine
include fever, redness, soreness and swelling at the injection site,
nausea, headaches, tiredness and aching muscles.
Page 4
If spots develop, cover and avoid direct contact with
people with low immunity until the spots dry out.
Spread by direct skin contact during all types of
sexual activity. More than 80% of people (males
and females) will be infected with at least one
type of genital HPV at some time.
Symptoms depend on the HPV type but often
there are no symptoms. HPV can be detected
on a Pap smear test or genital warts may
develop.
Complications HPV can cause genital warts;
cervical cancer and some cancers of the vulva,
vagina, penis and anus. In Australia an estimated
700 cases of cervical cancer are reported each
year, and in 2005 cervical cancer led to 216
deaths in women.
Human Papillomavirus (HPV) vaccine
• Vaccination can help protect males and
females against some of the most common
types of HPV that can lead to disease and
cancer.
• It is most effective when given before a
person becomes sexually active.
Common side effects of the HPV vaccine
include soreness, swelling and redness at
the injection site, headache, low grade fever,
dizziness and fainting, nausea and vomiting.
IMPORTANT
If my daughter has been vaccinated, does she
still need a pap test? Currently pap tests are
recommended every 2 years for women once
they are 18 years of age so early changes caused
by HPV can be monitored and/or treated to
prevent cancer.
Vaccination together with pap tests are the most
effective way of preventing cervical cancer.
For further information visit health.act.gov.au/immunisation