Immunizations Consent Form

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

Step 1: Student Information
Last Name	First Name	Preferred Name
Birth Date (yyyy/mm/dd)	Ontario Health Card Number (9 digits)	School
Parent/Guardian Name	Relationship to Student	Teacher’s Name
Parent/Guardian Daytime Phone Number (e.g., (705) 721-7520)	Alternative Phone Number (e.g., (705) 721-7520)	Grade

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?	Yes No
Has the student ever had a serious reaction to a previous vaccine or history of fainting?	Yes No
Does the student have a weakened immune system or taking a medication that increases the risk of infection (e.g., corticosteroids)?	Yes No
Does the student have a bleeding disorder?	Yes No
Does the student have a medical condition we should know about?	Yes No
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	Yes No	Date (yyyy/mm/dd)
• Hepatitis B Vaccine	Yes No	Date(s) (yyyy/mm/dd)
• Human Papillomavirus (HPV) Vaccine	Yes No	Date(s) (yyyy/mm/dd)

Step 3: Consent for Immunization (Check YES OR NO)
Meningococcal ACYW-135 Vaccine *REQUIRED FOR SCHOOL ATTENDANCE				For Public Health Initials Only
Yes	I authorize Simcoe Muskoka District Health Unit to administer one dose of Meningococcal ACYW-135 vaccine.	No	DO NOT administer Meningococcal ACYW-135 vaccine.	R1	R2
Hepatitis B Vaccine				For Public Health Initials Only
Yes	I authorize Simcoe Muskoka District Health Unit to administer two doses of Hepatitis B vaccine.	No	DO NOT administer Hepatitis B vaccine.	R1	R2
HPV Vaccine				For Public Health Initials Only
Yes	I authorize Simcoe Muskoka District Health Unit to administer two doses of HPV vaccine.	No	DO NOT administer HPV 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	Date (yyyy/mm/dd)	X	Date (yyyy/mm/dd)
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	Date (yyyy/mm/dd)	Student Initial	Date (yyyy/mm/dd)

PUBLIC HEALTH USE ONLY – Telephone Parental Awareness
Date called:	Phone number called:	Time:	Meningococcal ACYW-135 Vaccine	Yes	No
Consent obtained from:		Relationship to student:	Hepatitis B Vaccine	Yes	No
Nurse Signature:			HPV Vaccine	Yes	No

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

PREVENT CANCERS

There are different types of human papillomavirus (HPV). Many people do not know they are infected and never develop symptoms. HPV infections can cause many cancers of the mouth, head and neck, cervix and genitals, and genital warts.

How can I protect myself from HPV?

Get the vaccine. For optimal effectiveness, the series should start prior to exposure.
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 www.smdhu.org for more information.

What are the benefits of getting the HPV vaccine in Grade 7?

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. People can get HPV from having sexual contact of any kind with another person. HPV is common and 8 out of 10 people will get HPV at least once in their lifetime. Someone can have HPV for many years and not know it.
Individuals who start the vaccine series between the ages of 9 and 14, only require a two-dose series. The HPV vaccine becomes a three-dose series if you initiate vaccination on or after their 15th birthday.
HPV vaccine is free until the end of Grade 12.

PREVENT MENINGITIS

Meningococcal disease is very rare, but it can become life threatening quickly. It is the leading cause of bacterial meningitis in teens and young adults. It can cause strokes, hearing loss, seizures, brain damage, or blood infections. This vaccine or a valid exemption is needed for school attendance. It may also be needed for travel or post-secondary education.

How is meningitis contracted and how do I protect myself?

Through close, direct contact (coughing or sharing things like food, drinks, kissing 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.
Get the vaccine.
Do not share food, drinks, or utensils.

What is the benefit of getting the Meningococcal vaccine in Grade 7?

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, which protects 80% to 85% of teens against this disease.

PREVENT LIVER CANCER

The hepatitis B (HB) virus can cause inflammation of the liver, which can damage it. It can also cause cancer. Some people have no symptoms of infection and others get very sick. It can spread from improper cleaning of spa, tattoo, medical and dental equipment. This vaccine may be needed before travel and for some careers (e.g. health care).

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 HB. Talk to your parents, health care provider or go to www.smdhu.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 are the benefits of getting the Hepatitis B vaccine in Grade 7?

If all doses are received, the vaccine protects more than 95% against HB. The protection lasts at least 15 years or more for most people.
If a student starts this two-dose series but does not receive the second dose before their 16th birthday, they must complete a three-dose series.
HB vaccine is free until the end of Grade 12.

"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."

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