Recommended vaccine for
YEAR 7 students,
YEAR 9 CATCH-UP AND
YEAR 10 CATCH-UP (2013 ONLY)
Diphtheria, tetanus
and pertussis
(whooping cough)
Please read the information provided then
complete the consent form.
■ Your local council will be visiting your school soon for this
immunisation program. If you have any questions or concerns
please contact them as soon as possible.
■ THIS VACCINE IS FREE FOR YOUR CHILD THIS
YEAR ONLY.
■ If you have medical information about your child that will assist
council, please write it on the consent form.
Important information for you to keep
FACT SHEET
WHAT IS Diphtheria
Diphtheria is caused by bacteria which may be
found in the mouth, throat and nose. Diphtheria
causes a membrane to grow around the
inside of the throat. This can make it difficult
to swallow, breathe and can even lead to
suffocation.
The bacteria produce a poison which can
spread around the body and cause serious
complications and death.
Diphtheria can be caught through coughs and
sneezes from an infected person.
WHAT IS Tetanus
Tetanus is caused by bacteria which are present
in soils, dust and manure.
The bacteria can enter the body through a
wound which may be as small as a pin prick.
Tetanus cannot be passed from person to
person.
Tetanus is an often fatal disease which affects
the nervous system. It causes muscle spasms,
breathing difficulties and painful convulsions.
WHAT IS Whooping cough
(PERTUSSIS)
Whooping cough is a highly contagious disease
which affects the air passages and breathing.
The disease causes severe coughing spasms and
gasping for breath. Coughing spasms are often
followed by vomiting and the cough can last for
months.
Whooping cough is most serious in babies
under 12 months of age who often require
admission to hospital. Whooping cough can
lead to complications such as convulsions,
pneumonia, inflammation of the brain,
permanent brain and lung damage. Around one
in every 200 children under six months of age
who catches whooping cough will die.
Whooping cough can be caught through coughs
and sneezes from an infected person. Parents
and family members can infect babies.
Whooping cough immunity decreases over
time. Therefore a booster dose of whooping
cough vaccine is recommended for teenagers
to protect them and to reduce the spread of
whooping cough in the community.
Because of the effective vaccine, tetanus is now
rare in Australia. It still occurs in adults who have
never been immunised against the disease or
who have not had their booster vaccines.
It is important to return
the CONSENT form to
school by the due date
even if your child is not
being vaccinated
Diphtheria, tetanus and
PERTUSSIS (whooping cough)
vaccine (Boostrix® / Adacel®)
The diphtheria, tetanus and pertussis (whooping
cough) vaccine contains a small amount
of diphtheria and tetanus toxins which are
modified to make them harmless, small parts
of purified components of the virus that causes
whooping cough and preservative.
The whooping cough component in the vaccine
is different to previous triple antigen vaccine. It
causes fewer local injection site reactions, fever
and other reactions.
The vaccine is safe and well tolerated.
Worldwide millions of doses have been given.
Most side-effects are minor and disappear
quickly.
For possible side-effects – see over
Further information
If you require more information please contact your
local council, family doctor or see these websites:
www.dhhs.tas.gov.au/peh/immunisation
www.immunise.health.gov.au
Recommended vaccine for YEAR 7 students,
YEAR 9 CATCH-UP AND YEAR 10 CATCH-UP
(2013 ONLY)
It is important to return the
CONSENT form to school by
the due date even if your child
is not being vaccinated
Diphtheria, tetanus and pertussis
(whooping cough)
2013/2014 SCHEDULE OF FREE VACCINES
What if my child has already
received a tetanus vaccine
(eg. ADT™)?
Students should still be vaccinated with Boostrix®
or Adacel® vaccine to provide protection against
diphtheria, tetanus and pertussis (whooping cough).
There is no minimum time to wait if ADT™,
which does not contain whooping cough, has been
previously given.
Possible side-effects of
diphtheria, tetanus and
PERTUSSIS vaccination
Severe allergic reactions are rare. Most side-effects
are minor and quickly disappear. The following
reactions may occur soon after the immunisation:
■ mild temperature (below 39°C)
■ pain, redness and swelling at the injection site
■ temporary small lump at the injection site
■ feeling unwell
If mild reactions do occur, the side-effects can be
reduced by:
■ applying a cold wet cloth on sore injection site
■ taking paracetamol to reduce any discomfort
YEAR 7
YEAR 9
YEAR 10
HUMAN PAPILLOMA
VIRUS (HPV)
ü
(boys ONLY)
Diphtheria, TETANUS
AND PERTUSSIS
(WHOOPING COUGH)
ü
(CATCH-UP) (2013 ONLY)
Chickenpox
(Varicella)
ü
ü
ü
ü
ü
Hepatitis B
(2013 ONLY)
How to complete the consent form after reading the
attached information:
1
Please complete with the details of the child.
2
YES, if you wish to have your child immunised, complete
and sign this section.
OR
3
NO, if you do not wish to have your child immunised,
complete and sign this section.
ü READ FACT SHEET
ü SIGN THIS CONSENT FORM
ü RETURN TO SCHOOL BY DUE DATE
Recommended vaccine foR YEAR 7 students,
YEAR 9 catcH-uP and YEAR 10 catcH-uP (2013 onLY)
If reactions are severe or persistent, or if you are
worried about your child, contact your doctor or
hospital.
People who receive vaccination must stay where
they were vaccinated for 15 minutes.
YEAR 8
Diphtheria, tetanus and pertussis
(whooping cough)
1
IMMUNISATION CONSENT FORM
1
PLease comPLete in Pen
STUDENT DETAILS
MEDICARE NUMBER
(NUMBER BESIDE CHILD'S NAME)
FAMILy NAME
FIRSt NAME
RESIDENtIAL ADDRESS
PoStCoDE
Having more than one injection on the same day
does not increase the chance of a child having a
reaction to the vaccines.
DAtE oF BIRtH
/
/
SCHooL
Is your child of Aboriginal or torres Strait Islander origin?
Yes
SEx
femaLe
yEAR
7
maLe
9
10
no
PRE-IMMUNISATION CHECkLIST (please mark appropriate box)
Has your child had:
a severe reaction following any vaccine
Yes
no
any severe allergies
Yes
no
If you answered yes to any of the above questions, please provide details
if you ticked yes to any of the above questions or if you think there may be any reason why your child should not have this vaccination,
please discuss this with your family doctor before consenting to vaccination.
PARENT/GUARDIAN DETAILS
FAMILy NAME
FIRSt NAME
EMAIL
DAytIME PHoNE NUMBER
2
2
MoBILE
Parent/Guardian, please sign if you AGREE to your child receiving diphtheria, tetanus and pertussis immunisation at school.
Yes, I have read and understood the information given to me about vaccination, including risks and side-effects. I understand that I am giving
consent for a dose of diphtheria, tetanus and pertussis vaccine to be given.
OR
I give consent for the above child to be vaccinated.
PARENt / GUARDIAN SIGNAtURE
3
DAtE
/
/
OR
3
Parent/guardian, please sign if you DO NOT want your child to receive diphtheria, tetanus and pertussis immunisation at school.
I have read and understood the information given to me about vaccination, including risks and side-effects. No, I do not wish to have my child
immunised with diphtheria, tetanus and pertussis vaccine at this time. Please complete the following questions.
I have planned vaccination with my family doctor
Yes
no
My child has recently had diphtheria, tetanus and pertussis vaccine
Yes
no
other reason, please give details
PARENt / GUARDIAN SIGNAtURE
PLease tuRn oveR foR PRivacY statement
DAtE
/
/