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Immunizations Consent Form

CONSENT FOR SCHOOL IMMUNIZATIONS
Meningococcal C-ACYW-135, Hepatitis B, Human Papillomavirus

Step 1: Student Information





(yyyy/mm/dd)


(9 digits)






(e.g., (705) 721-7520)


(e.g., (705) 721-7520)


Step 2: Health History (Check YES or NO)   If yes, please explain
Does the student have any of the following allergies: yeast, aluminum, latex, diphtheria or tetanus toxoid protein?
Has the student ever had a serious reaction to a previous vaccine or history of fainting?
Does the student have a weakened immune system or taking a medication that increases the risk of infection (e.g., corticosteroids)?
Does the student have a bleeding disorder?
Does the student have a medical condition we should know about?
Has the student already received any of the following vaccines:
• Meningococcal C-ACYW-135 Vaccine
Note: Men-C-C received at 12 months of age is not Men-C-ACYW-135

• Hepatitis B Vaccine
• Human Papillomavirus (HPV) Vaccine
Step 3: Consent for Immunization (Check YES OR NO)
Meningococcal ACYW-135 Vaccine *REQUIRED FOR SCHOOL ATTENDANCE For Public Health
Initials Only
I authorize Simcoe Muskoka District Health Unit to administer one dose of Meningococcal ACYW-135 vaccine. DO NOT administer Meningococcal ACYW-135 vaccine. R1 R2
Hepatitis B Vaccine For Public Health
Initials Only
I authorize Simcoe Muskoka District Health Unit to administer two doses of Hepatitis B vaccine. DO NOT administer Hepatitis B vaccine. R1 R2
Human Papillomavirus (HPV-9) Vaccine For Public Health
Initials Only
I authorize Simcoe Muskoka District Health Unit to administer two doses of HPV-9 vaccine. DO NOT administer HPV-9 vaccine. R1 R2
Step 4: Signature of Parent / Guardian / Individual
This consent is valid for two years. I understand that I can withdraw my consent at any time as well as ask any questions by calling the Simcoe Muskoka District Health Unit at 705-721-7520.
This information is being collected pursuant to the Protection and Promotion Act, R.S.O. 1990, c.H.7 and will be retained, used, disclosed and disposed of in accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health Information Protection Act, 2004, S.O.c.3 and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. This information may be shared with other health care providers.
X
X
Parent/Guardian Signature
Student Signature

To be completed by the student, at school, on the day of the clinic (Round 1): To be completed by the student, at school, on the day of the clinic (Round 2):
Student Initial
Student Initial
PUBLIC HEALTH USE ONLY – Telephone Parental Awareness



Men-C-ACYW-135 Vaccine


Hepatitis B Vaccine
Nurse Signature:
Human Papillomavirus (HPV-9)

PLEASE RETURN COMPLETED CONSENT FORM TO THE SCHOOL

For more information or detailed fact sheet on each vaccine

please visit our website https://www.simcoemuskokahealth.org/grade7

Hepatitis B Vaccine

What is Hepatitis B?

Hepatitis B (HB) is a virus that affects your liver. It can cause damage, swelling or cancer of the liver. Unfortunately, there is no cure for Hepatitis B.

How can I get Hepatitis B?

  • Through contact with an infected person's blood and/or body fluids.
  • The virus can stay alive on things like razors or toothbrushes for up to one week.
  • Many people with Hepatitis B don't know they have the virus and may go on to infect others.

How can I protect myself from the Hepatitis B virus?

  • Get the vaccine.
  • Practice sexual abstinence, which means not participating in any sexual activity with another person (i.e. avoiding all types of intimate genital contact).
  • If you are considering being sexually active, there are ways to protect yourself against Hepatitis B. Talk to your parents, health care provider or go to https://www.simcoemuskokahealth.org for more information.
  • Make sure sterile tools are used for tattooing or body piercing.
  • Do not share razors, toothbrushes, or other personal care items.

What is the benefit of getting the Hepatitis B vaccine?

  • If all doses are received, the vaccine protects more than 95% against Hepatitis B. The protection lasts at least 15 years or more for most people.

This vaccine is only publicly funded until the end of Grade 8.

Meningococcal Conjugate ACYW Vaccine

What is meningitis?

Meningitis is an infection of the fluid around a person’s spinal cord and brain. It can be caused by different viruses or bacteria. Neisseria meningitidis is one of these bacteria. Meningococcal vaccine protects against 4 different types of this bacteria.

How can I get meningitis?

  • Through close, direct contact (kissing, coughing or sharing things like food, drinks and musical instruments).
  • People can carry the bacteria in their nose and throat without feeling sick. People become sick when the bacteria gets into their blood and body fluids.
  • This can lead to brain damage and sometimes death within just a few hours.

How can I protect myself from meningococcal bacteria?

  • Get the vaccine.
  • Do not share food, drinks, or utensils.

What is the benefit of getting the Meningococcal vaccine?

  • You have likely already received a meningococcal vaccine (e.g. Menjugate®) for infants that protects against one type of the bacteria.
  • The grade 7 Meningococcal vaccine protects against four types of the bacteria.
  • This vaccine protects 80% to 85% of teens against disease caused by these four types.

Human Papillomavirus Vaccine

What is human papillomavirus (HPV)?

HPV is short for human papillomavirus. HPV can cause different kinds of cancer (mouth and throat, cervical, anal, and genital) and genital warts. HPV vaccine is for everyone, regardless of gender.

How can I protect myself from HPV?

  • Get the vaccine.
  • Practice sexual abstinence, which means not participating in any sexual activity with another person (i.e. avoiding all types of intimate genital contact).
  • If you are considering being sexually active, there are ways to protect yourself against HPV. Talk to your parents, health care provider or go to https://www.simcoemuskokahealth.org for more information.

What is the benefit of getting the HPV vaccine?

  • Research has shown that the HPV vaccine can prevent most cases of cervical cancer if all doses are given before a person becomes sexually active.
  • It is effective in preventing penile (cancer of the penis), anal and throat cancers.
  • HPV vaccine also prevents genital warts.
Most Common Reactions After Vaccination Less Common Reactions After Vaccination Very Rare Reactions After Vaccination
Redness, pain and/or swelling where the needle was given Tiredness, headache and/or slight fever Severe allergic reaction (Trouble breathing, swelling of the face or mouth, hives)
**Clinic Nurses are trained to treat severe allergic reactions.

"The Health Unit collects personal information in the course of doing business. Personal information about you is collected directly from you or from the person acting on your behalf. Personal health information collected may include, for example, your name, date of birth, address, contact information, health card number, health history, and information you provide during visits or calls to the health unit."

For more information or detailed fact sheet on each vaccine
please visit our website at smdhu.org/grade7

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