Year 7 ACT High School Immunisation Program 2022
Information
To do:
1. Read the information. This
information card can be detached
and retained for your reference.
2. Sign the consent card, even if your
child is not being vaccinated
at school.
3. Return the consent card to school
as soon as possible.
4. Talk to your child about vaccination.
Please advise the Child and Adolescent
Immunisation Team on 02 5124 1585 if
your child changes schools throughout
the year or if you wish to change your
consent.
The Child and Adolescent
Immunisation Team provide this
free immunisation program and
will be visiting your child’s school
All Year 7 students are offered the
following vaccines:
• Human Papillomavirus (HPV)
(1 dose required)
• Diphtheria-Tetanus-Pertussis
(dTpa) (1 dose required)
during 2024.
Year 7 ACT High School Immunisation Program 2024
Information
Year 7 ACT High School Immunisation Program 2022
Information
To do:
1. Read the information. This
information card can be detached
and retained for your reference.
2. Sign the consent card, even if your
child is not being vaccinated
at school.
3. Return the consent card to school
as soon as possible.
4. Talk to your child about vaccination.
Please advise the Child and Adolescent
Immunisation Team on 02 5124 1585 if
your child changes schools throughout
the year or if you wish to change your
consent.
The Child and Adolescent
Immunisation Team provide this
free immunisation program and
will be visiting your child’s school
All Year 7 students are offered the
following vaccines:
• Human Papillomavirus (HPV)
(1 dose required)
• Diphtheria-Tetanus-Pertussis
(dTpa) (1 dose required)
Year 7 ACT High School Immunisation Program 2022
Information
To do:
1. Read the information. This
information card can be detached
and retained for your reference.
2. Sign the consent card, even if your
child is not being vaccinated
at school.
3. Return the consent card to school
as soon as possible.
4. Talk to your child about vaccination.
Please advise the Child and Adolescent
Immunisation Team on 02 5124 1585 if
your child changes schools throughout
the year or if you wish to change your
consent.
The Child and Adolescent
Immunisation Team provide this
free immunisation program and
will be visiting your child’s school
All Year 7 students are offered the
following vaccines:
• Human Papillomavirus (HPV)
(1 dose required)
• Diphtheria-Tetanus-Pertussis
(dTpa) (1 dose required)
Year 7 ACT High School Immunisation Program 2022
Information
To do:
1. Read the information. This
information card can be detached
and retained for your reference.
2. Sign the consent card, even if your
child is not being vaccinated
at school.
3. Return the consent card to school
as soon as possible.
4. Talk to your child about vaccination.
Please advise the Child and Adolescent
Immunisation Team on 02 5124 1585 if
your child changes schools throughout
the year or if you wish to change your
consent.
The Child and Adolescent
Immunisation Team provide this
free immunisation program and
will be visiting your child’s school
All Year 7 students are offered the
following vaccines:
• Human Papillomavirus (HPV)
(1 dose required)
• Diphtheria-Tetanus-Pertussis
(dTpa)
(1 dose required)
Vaccine information
• Vaccines are administered by an injection to the upper arm.
• All vaccines can cause mild reactions. They are usually short
lasting and do not require any special treatment.
• Very rarely an individual may experience a severe allergic
reaction to a vaccine. The registered nurses in the Child and
Adolescent Immunisation Team are trained to recognise
and manage any immediate severe reactions. These
generally occur within the rst 15 minutes after receiving a
vaccine. All students are monitored closely by the registered
nurses during this time.
Program information
What if my child is absent or refuses the vaccines on the
day that the nurses visit the school?
If you have completed and returned a consent card with 'yes'
consent, you will receive a letter advising you of any missed
vaccines and how to catch them up at your GP, via My DHR or
by post.
What if my child is not participating in the
High School Immunisation Program?
Please still complete the consent card and return it to your
school as soon as possible. You will be able to access these
vaccines FREE from your GP from 1st June 2023 up until your
child’s 20th birthday. Some GPs may charge a consultation fee.
What will happen to my child’s information?
Information is shared with the ACT Health Immunisation Unit
in the event of an Adverse Event Following Immunisation and
for surveillance of immunisation coverage. Please see our
websites for more details.
How will I receive a record of my child’s immunisation?
Students will receive a card with post vaccination information on
the day. All vaccines given to students through the High School
Immunisation Program will be uploaded to the Australian
Immunisation Register (AIR). To access an official
immunisation record, please visit your MyGov account, or
download the Medicare Express Plus app on your mobile phone.
• Tetanus disease is caused when a bacteria enters
the body through a cut or a wound and causes the
production of a harmful toxin.
•
Symptoms may include painful muscle spasms,
convulsions and lock jaw.
• It can cause serious medical complications
including death.
• Diphtheria is an acute infectious disease caused by
bacteria that infects the mouth, nose and throat.
• It is easily spread through coughing and sneezing
from an infected person and may cause a sore
throat, hoarseness, fever, and difculty breathing/
swallowing.
• Major heart and nervous system complications can
occur sometimes resulting in death.
• Pertussis is a highly contagious respiratory disease.
• It is spread though respiratory droplets from
sneezing and coughing.
• Complications include, pneumonia, convulsions
and brain damage.
• Every year in Australia, an average of 1 death and
more than 200 hospitalisations related to pertussis
occurs in babies less than 6 months old.
• The dTpa vaccine provides protection for all three
diseases.
• This dose in Year 7 is a booster dose from those
given in early childhood
• Common side effects of the vaccine include fever,
nausea, headaches and aching muscles as well as
redness, soreness and swelling at the injection site.
Tetanus
Diphtheria
Pertussis (Whooping Cough)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
• HPV is the name of a group of viruses that can
cause genital warts and lead to some cancers in
both males and females.
• It is spread by skin contact during all types of
sexual activity.
• Genital warts may develop however there are
often no symptoms of HPV. HPV can be detected
through cervical screening.
Human Papillomavirus (HPV)
• Vaccination can help protect everyone from some
of the most common types of HPV.
• The vaccine is most effective when given before a
person becomes sexually active.
• Common side effects of the vaccine include
headache, fever, dizziness/fainting, nausea and
vomiting as well as redness, soreness and swelling
at the injection site.
Human Papillomavirus (HPV) Vaccine
Important
Does my child still need the dTpa vaccine if they
have recently received a tetanus booster vaccine
after an injury?
An ADT Booster (Adsorbed Diphtheria and Tetanus)
Vaccine given after an injury does not protect against
Pertussis. Therefore it is recommended and safe for
the student to still receive this dTpa vaccine.
ACT Health Immunisation Unit
Phone: 02 5124 9800
Website: www.health.act.gov.au/
services/immunisation
Canberra Health Services High
School Immunisation Program
Monday to Friday 8am - 4pm
Phone: 02 5124 1585
Website: www.health.act.gov.
au/services-and-programs/
immunisation/adolescents (or use
QR code on the right)
Where can I get more information?
Accessibility (how to get this
information in other ways)
If
you want to receive this
in
formation:
• in larger print
• or hear it on audio
pl
ease telephone (02) 5124 0000.
ww
w.health.act.gov.au | Phone: 132281
© Australian Capital Territory, Canberra
Ph 131 4
50
Vaccine information
• Vaccines are administered by an injection to the upper arm.
• All vaccines can cause mild reactions. They are usually short
lasting and do not require any special treatment.
• Very rarely an individual may experience a severe allergic
reaction to a vaccine. The registered nurses in the Child and
Adolescent Immunisation Team are trained to recognise
and manage any immediate severe reactions. These
generally occur within the rst 15 minutes after receiving a
vaccine. All students are monitored closely by the registered
nurses during this time.
Program information
What if my child is absent or refuses the vaccines on the
day that the nurses visit the school?
If you have completed and returned a consent card with 'yes'
consent, you will receive a letter advising you of any missed
vaccines and how to catch them up at your GP, via My DHR or
by post.
What if my child is not participating in the
High School Immunisation Program?
Please still complete the consent card and return it to your
school as soon as possible. You will be able to access these
vaccines FREE from your GP from 1st June 2023 up until your
child’s 20th birthday. Some GPs may charge a consultation fee.
What will happen to my child’s information?
Information is shared with the ACT Health Immunisation Unit
in the event of an Adverse Event Following Immunisation and
for surveillance of immunisation coverage. Please see our
websites for more details.
How will I receive a record of my child’s immunisation?
Students will receive a card with post vaccination information on
the day. All vaccines given to students through the High School
Immunisation Program will be uploaded to the Australian
Immunisation Register (AIR). To access an official
immunisation record, please visit your MyGov account, or
download the Medicare Express Plus app on your mobile phone.
• Tetanus disease is caused when a bacteria enters
the body through a cut or a wound and causes the
production of a harmful toxin.
•
Symptoms may include painful muscle spasms,
convulsions and lock jaw.
• It can cause serious medical complications
including death.
• Diphtheria is an acute infectious disease caused by
bacteria that infects the mouth, nose and throat.
• It is easily spread through coughing and sneezing
from an infected person and may cause a sore
throat, hoarseness, fever, and difculty breathing/
swallowing.
• Major heart and nervous system complications can
occur sometimes resulting in death.
• Pertussis is a highly contagious respiratory disease.
• It is spread though respiratory droplets from
sneezing and coughing.
• Complications include, pneumonia, convulsions
and brain damage.
• Every year in Australia, an average of 1 death and
more than 200 hospitalisations related to pertussis
occurs in babies less than 6 months old.
• The dTpa vaccine provides protection for all three
diseases.
• This dose in Year 7 is a booster dose from those
given in early childhood
• Common side effects of the vaccine include fever,
nausea, headaches and aching muscles as well as
redness, soreness and swelling at the injection site.
Tetanus
Diphtheria
Pertussis (Whooping Cough)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
• HPV is the name of a group of viruses that can
cause genital warts and lead to some cancers in
both males and females.
• It is spread by skin contact during all types of
sexual activity.
• Genital warts may develop however there are
often no symptoms of HPV. HPV can be detected
through cervical screening.
Human Papillomavirus (HPV)
• Vaccination can help protect everyone from some
of the most common types of HPV.
• The vaccine is most effective when given before a
person becomes sexually active.
• Common side effects of the vaccine include
headache, fever, dizziness/fainting, nausea and
vomiting as well as redness, soreness and swelling
at the injection site.
Human Papillomavirus (HPV) Vaccine
Important
Does my child still need the dTpa vaccine if they
have recently received a tetanus booster vaccine
after an injury?
An ADT Booster (Adsorbed Diphtheria and Tetanus)
Vaccine given after an injury does not protect against
Pertussis. Therefore it is recommended and safe for
the student to still receive this dTpa vaccine.
ACT Health Immunisation Unit
Phone: 02 5124 9800
Website: www.health.act.gov.au/
services/immunisation
Canberra Health Services High
School Immunisation Program
Monday to Friday 8am - 4pm
Phone: 02 5124 1585
Website: www.health.act.gov.
au/services-and-programs/
immunisation/adolescents (or use
QR code on the right)
Where can I get more information?
Accessibility (how to get this
information in other ways)
If
you want to receive this
in
formation:
• in larger print
• or hear it on audio
pl
ease telephone (02) 5124 0000.
ww
w.health.act.gov.au | Phone: 132281
© Australian Capital Territory, Canberra
Ph 131 4
50
Vaccine information
• Vaccines are administered by an injection to the upper arm.
• All vaccines can cause mild reactions. They are usually short
lasting and do not require any special treatment.
• Very rarely an individual may experience a severe allergic
reaction to a vaccine. The registered nurses in the Child and
Adolescent Immunisation Team are trained to recognise
and manage any immediate severe reactions. These
generally occur within the rst 15 minutes after receiving a
vaccine. All students are monitored closely by the registered
nurses during this time.
Program information
What if my child is absent or refuses the vaccines on the
day that the nurses visit the school?
If you have completed and returned a consent card with 'yes'
consent, you will receive a letter advising you of any missed
vaccines and how to catch them up at your GP, via My DHR or
by post.
What if my child is not participating in the
High School Immunisation Program?
Please still complete the consent card and return it to your
school as soon as possible. You will be able to access these
vaccines FREE from your GP from 1st June 2023 up until your
child’s 20th birthday. Some GPs may charge a consultation fee.
What will happen to my child’s information?
Information is shared with the ACT Health Immunisation Unit
in the event of an Adverse Event Following Immunisation and
for surveillance of immunisation coverage. Please see our
websites for more details.
How will I receive a record of my child’s immunisation?
Students will receive a card with post vaccination information on
the day. All vaccines given to students through the High School
Immunisation Program will be uploaded to the Australian
Immunisation Register (AIR). To access an official
immunisation record, please visit your MyGov account, or
download the Medicare Express Plus app on your mobile phone.
• Tetanus disease is caused when a bacteria enters
the body through a cut or a wound and causes the
production of a harmful toxin.
•
Symptoms may include painful muscle spasms,
convulsions and lock jaw.
• It can cause serious medical complications
including death.
• Diphtheria is an acute infectious disease caused by
bacteria that infects the mouth, nose and throat.
• It is easily spread through coughing and sneezing
from an infected person and may cause a sore
throat, hoarseness, fever, and difculty breathing/
swallowing.
• Major heart and nervous system complications can
occur sometimes resulting in death.
• Pertussis is a highly contagious respiratory disease.
• It is spread though respiratory droplets from
sneezing and coughing.
• Complications include, pneumonia, convulsions
and brain damage.
• Every year in Australia, an average of 1 death and
more than 200 hospitalisations related to pertussis
occurs in babies less than 6 months old.
• The dTpa vaccine provides protection for all three
diseases.
• This dose in Year 7 is a booster dose from those
given in early childhood
• Common side effects of the vaccine include fever,
nausea, headaches and aching muscles as well as
redness, soreness and swelling at the injection site.
Tetanus
Diphtheria
Pertussis (Whooping Cough)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
• HPV is the name of a group of viruses that can
cause genital warts and lead to some cancers in
both males and females.
• It is spread by skin contact during all types of
sexual activity.
• Genital warts may develop however there are
often no symptoms of HPV. HPV can be detected
through cervical screening.
Human Papillomavirus (HPV)
• Vaccination can help protect everyone from some
of the most common types of HPV.
• The vaccine is most effective when given before a
person becomes sexually active.
• Common side effects of the vaccine include
headache, fever, dizziness/fainting, nausea and
vomiting as well as redness, soreness and swelling
at the injection site.
Human Papillomavirus (HPV) Vaccine
Important
Does my child still need the dTpa vaccine if they
have recently received a tetanus booster vaccine
after an injury?
An ADT Booster (Adsorbed Diphtheria and Tetanus)
Vaccine given after an injury does not protect against
Pertussis. Therefore it is recommended and safe for
the student to still receive this dTpa vaccine.
ACT Health Immunisation Unit
Phone: 02 5124 9800
Website: www.health.act.gov.au/
services/immunisation
Canberra Health Services High
School Immunisation Program
Monday to Friday 8am - 4pm
Phone: 02 5124 1585
Website: www.health.act.gov.
au/services-and-programs/
immunisation/adolescents (or use
QR code on the right)
Where can I get more information?
Accessibility (how to get this
information in other ways)
If
you want to receive this
in
formation:
• in larger print
• or hear it on audio
pl
ease telephone (02) 5124 0000.
ww
w.health.act.gov.au | Phone: 132281
© Australian Capital Territory, Canberra
Ph 131 4
50
What if my child is absent or refuses the vaccines on the
day that the nurses visit the school?
If you have completed and returned a consent card with ‘yes’
consent, you will receive a letter (via MyDHR or post) advising
you of any missed vaccines and how to catch up at either your
GP or participating pharmacy.
Monday to Friday 8.30am - 4.30pm
Vaccine information
• Vaccines are administered by an injection to the upper arm.
• All vaccines can cause mild reactions. They are usually short
lasting and do not require any special treatment.
• Very rarely an individual may experience a severe allergic
reaction to a vaccine. The registered nurses in the Child and
Adolescent Immunisation Team are trained to recognise
and manage any immediate severe reactions. These
generally occur within the rst 15 minutes after receiving a
vaccine. All students are monitored closely by the registered
nurses during this time.
Program information
What if my child is absent or refuses the vaccines on the
day that the nurses visit the school?
If you have completed and returned a consent card with 'yes'
consent, you will receive a letter advising you of any missed
vaccines and how to catch them up at your GP, via My DHR or
by post.
What if my child is not participating in the
High School Immunisation Program?
Please still complete the consent card and return it to your
school as soon as possible. You will be able to access these
vaccines FREE from your GP from 1st June 2023 up until your
child’s 20th birthday. Some GPs may charge a consultation fee.
What will happen to my child’s information?
Information is shared with the ACT Health Immunisation Unit
in the event of an Adverse Event Following Immunisation and
for surveillance of immunisation coverage. Please see our
websites for more details.
How will I receive a record of my child’s immunisation?
Students will receive a card with post vaccination information on
the day. All vaccines given to students through the High School
Immunisation Program will be uploaded to the Australian
Immunisation Register (AIR). To access an official
immunisation record, please visit your MyGov account, or
download the Medicare Express Plus app on your mobile phone.
• Tetanus disease is caused when a bacteria enters
the body through a cut or a wound and causes the
production of a harmful toxin.
•
Symptoms may include painful muscle spasms,
convulsions and lock jaw.
• It can cause serious medical complications
including death.
• Diphtheria is an acute infectious disease caused by
bacteria that infects the mouth, nose and throat.
• It is easily spread through coughing and sneezing
from an infected person and may cause a sore
throat, hoarseness, fever, and difculty breathing/
swallowing.
• Major heart and nervous system complications can
occur sometimes resulting in death.
• Pertussis is a highly contagious respiratory disease.
• It is spread though respiratory droplets from
sneezing and coughing.
• Complications include, pneumonia, convulsions
and brain damage.
• Every year in Australia, an average of 1 death and
more than 200 hospitalisations related to pertussis
occurs in babies less than 6 months old.
• The dTpa vaccine provides protection for all three
diseases.
• This dose in Year 7 is a booster dose from those
given in early childhood
• Common side effects of the vaccine include fever,
nausea, headaches and aching muscles as well as
redness, soreness and swelling at the injection site.
Tetanus
Diphtheria
Pertussis (Whooping Cough)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
• HPV is the name of a group of viruses that can
cause genital warts and lead to some cancers in
both males and females.
• It is spread by skin contact during all types of
sexual activity.
• Genital warts may develop however there are
often no symptoms of HPV. HPV can be detected
through cervical screening.
Human Papillomavirus (HPV)
• Vaccination can help protect everyone from some
of the most common types of HPV.
• The vaccine is most effective when given before a
person becomes sexually active.
• Common side effects of the vaccine include
headache, fever, dizziness/fainting, nausea and
vomiting as well as redness, soreness and swelling
at the injection site.
Human Papillomavirus (HPV) Vaccine
Important
Does my child still need the dTpa vaccine if they
have recently received a tetanus booster vaccine
after an injury?
An ADT Booster (Adsorbed Diphtheria and Tetanus)
Vaccine given after an injury does not protect against
Pertussis. Therefore it is recommended and safe for
the student to still receive this dTpa vaccine.
ACT Health Immunisation Unit
Phone: 02 5124 9800
Website: www.health.act.gov.au/
services/immunisation
Canberra Health Services High
School Immunisation Program
Monday to Friday 8am - 4pm
Phone: 02 5124 1585
Website: www.health.act.gov.
au/services-and-programs/
immunisation/adolescents (or use
QR code on the right)
Where can I get more information?
Accessibility (how to get this
information in other ways)
If
you want to receive this
in
formation:
• in larger print
• or hear it on audio
pl
ease telephone (02) 5124 0000.
ww
w.health.act.gov.au | Phone: 132281
© Australian Capital Territory, Canberra
Ph 131 4
50
What if my child is not participating in the High School
Immunisation Program?
Please still complete the consent card and return it to your school
as soon as possible. You will be able to access this vaccine FREE
form your GP or participating pharmacy up until your child’s 20th
birthday for dTpa and 26th birthday for the HPV vaccine. Some
GPs and pharmacies may charge a consultation
fee.
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
N S
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........
(date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Year 7 ACT High School Immunisation Program 2024
Please register for My DHR by using the
QR code otherwise all correspondence
will be sent by post.
I have legal parental responsibility of this child as: Name of Parent/Legal Guardian (e.g. JACK SMITH)
Name of Parent/Legal Guardian (e.g. JACK SMITH)
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the Meningococcal ACWY vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date
Yes I give consent for my child to
receive the Meningococcal ACWY
vaccine at school.
Meningococcal ACWY Vaccine
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Year 10 ACT High School Immunisation Program 2022
Consent Card
Once completed please return to your child’s school as soon as possible. Thank you.
Page 1 /1
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Signature Date
No I do not consent for my child to
receive the Meningococcal ACWY
vaccine at school.
No my child has already received
the Meningococcal ACWY vaccine
on ........ /....... /........ (date)
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Please register for My DHR by using the
QR code otherwise all correspondence
will be sent by post.
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as: Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as:
Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1
Year 7 ACT High School Immunisation Program 2022
Consent Card
Pre-vaccination checklist*
Please tick the appropriate box(es) if the student:
If you have ticked any box above, please describe: ....................................................................................................
...............................................................................................................................................................................................................................
*This consent card may be viewed by school staff. If there is any sensitive information you wish to condentially
discuss with nursing staff, please contact the Child and Adolescent Immunisation Team on 02 5124 1585.
Parent or legal guardian consent
I have read and understood the information provided regarding the benets and possible
side effects of the HPV vaccine and dTpa vaccine and note that I can withdraw consent
at any time.
has ever fainted when given an injection
has received a vaccine in the last 4
weeks
has any severe allergies
has a Severe Allergy/Anaphylaxis Care
Plan
has previously had a reaction to a
vaccine
is pregnant or breastfeeding
has a medical condition (e.g. epilepsy,
asthma, diabetes, including previous
Guillian-Barre syndrome and blood
borne illness)
Signature Date Signature Date
Yes I give consent for my child to
receive the HPV vaccine at school.
No I do not consent for my child to
receive the HPV vaccine at school.
No my child has already received
the HPV vaccine.
Human Papillomavirus (HPV) Vaccine
Signature Date Signature Date
Yes I give consent for my child to
receive the dTpa vaccine at school.
No I do not consent for my child to
receive the dTpa vaccine.
No my child has already received
the dTpa vaccine on ........ /....... /........ (date)
Diphtheria-Tetanus-Pertussis (dTpa) Vaccine
Once completed please return to your child’s school as soon as possible. Thank you.
Ofce use only: Complete details or afx label
URN: ...........................................................................................................................................................
Family Name: .....................................................................................................................................
Given Names:......................................................................................................................................
DOB: ..................................................................... Sex: .....................................................................
Parent/Guardian to complete all elds in CAPITAL letters using a black or blue pen.
Student details
Surname
Given and Middle Name/s
Date of Birth Gender
/ / Male Female Other
Country of Birth
Residential Street Address
Suburb Postcode
Name of School
Medicare Number
Number beside your child’s
name on the Medicare Card
Indigenous status
No Yes, Aboriginal Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander Decline to answer
Preferred language
English Other
Details of parent or legal guardian signing consent
Name of Parent/Legal Guardian (e.g. JACK SMITH)
I have legal parental responsibility of this child as:
Parent Legal Guardian
Mobile Number Best Alternative Number
Page 1