School Immunisation Program consent form for Year 7 students

As part of Queensland Health’s School Immunisation Program, every Year 7 student will be offered two free vaccinations as recommended in the National Immunisation Program. These are the Human papillomavirus (HPV) vaccine and Diphtheria, tetanus and pertussis (whooping cough) vaccine (dTpa).

This form should be completed to confirm that either you do, or do not, consent to your child being immunised as part of the School Immunisation Program. You will be asked to select your choice (Yes or No) in the consent sections at the end of the form.

Required fields are marked with an asterisk (*).

Student Details
Child's legal last name (surname)*
Child's legal first names *
Date of Birth *
Gender *
Does your child identify as either Aboriginal or Torres Strait Islander?
Is English your family's main language spoken at home?
Parent/legal guardian/authorised carer details.
Relationship to the student listed on this form: *
Please read and use tick boxes below to indicate if you wish or do not wish your child to receive immunisation at school.

About the School Immunisation Program vaccines

Human papillomavirus (HPV) vaccine

Human papillomavirus has been identified as important in preventing a range of cancers and other conditions in males and females. There is currently no treatment for HPV.

As well as causing many genital cancers, the virus is a major cause of mouth and throat cancers which have been on the increase in recent years.

It can also cause tumours in the air passages to the lungs.

More than 80 per cent of males and females have had a HPV infection at some time in their lives.

Most HPV infections do not cause any symptoms and people usually do not know they have the infection.

Most people clear the infection although between 10-20 per cent will continue to have the virus in their body. This can lead to the development of a range of cancers and other conditions later in life.

While there are many stories on social media about the risks of the vaccine against HPV, No serious side effects have been recorded during rigorous monitoring over this time.

What is the Human papillomavirus (HPV) vaccine?

  • HPV vaccine Gardasil®9 is given as two injectable doses with an interval of (at least) six months apart. It is important to ensure timely completion of the HPV schedule in the year it is commenced to maximise protection.

What are the benefits of receiving HPV vaccine?

  • The HPV vaccine protects boys and girls against nine types of HPV-related cancer and diseases by preventing infection.
  • Queensland Health has been using this vaccine for more than a decade. More than nine million doses of the vaccine have been given in Australia and more than 200 million doses worldwide.
  • There is currently no treatment for HPV.
  • The vaccine provides girls with the best protection against cervical cancer and is part of the National Cervical Screening Program.
  • It is important for boys to have the vaccine as one third of all HPV cancers occur in males.

Immunocompromised individuals

Immunocompromised children (with major medical conditions listed below) require three doses of Gardasil®9 given at 0, 2 and 6 months to attain adequate protection and may not be able to be vaccinated in the School Immunisation Program. Please consult your doctor to discuss HPV vaccination for your child.

Primary or secondary immunodeficiencies (B lymphocyte antibody and T lymphocyte or partial deficiencies); HIV infection; malignancy; organ transplantation; autoimmune disease; or significant immunosuppressive therapy (excluding asplenia or hyposplenia).

Diphtheria, tetanus and pertussis (whooping cough) vaccine (dTpa)

One dose of a combined booster vaccine against three organisms including whooping cough (pertussis), diphtheria and tetanus is offered.

Diphtheria

Diphtheria is caused by bacteria that can infect the mouth, throat and nose and results in an extremely sore throat and breathing difficulties.

It can produce nerve paralysis and heart failure. About one in 15 people infected with diphtheria will die.

Since 2014 Queensland has had 10 cases and one death from diphtheria.

Tetanus

Tetanus occurs when wounds are infected by bacteria present in soil. It causes painful muscle spasms, convulsions and lockjaw.

In Australia about three per cent of people who develop tetanus will die. Between 2016-2018 there has been six cases of tetanus in Queensland.

Pertussis (whooping cough)

Pertussis (whooping cough) is a highly contagious respiratory disease resulting in a severe cough that may last for months.

Infected people may gasp for air causing a ‘whooping’ sound and they may have severe coughing spasms followed by gagging and vomiting.

Infections in adolescents and adults are common and can lead to prolonged illness.

Whooping cough is highly contagious and can be deadly for newborn babies too young to be vaccinated.

Complications can include convulsions, pneumonia, coma, inflammation of the brain, permanent brain damage and long-term lung damage.

Vaccines given in childhood to protect against whooping cough, or having had whooping cough disease, do not provide lifelong protection.

Six Queensland babies died of whooping cough between 2000 and 2013.

Between 2016 and 2018 there was more than 3000 cases reported in Queensland.

Both HPV and dTpa vaccines are safe and effective.

Worldwide, extensive clinical trials and post implementation safety surveillance data indicate that these vaccines are well tolerated and extremely safe.

Why are students vaccinated at this age?

These vaccines are being provided in Year 7 as adolescents receiving vaccines before age 14 develop a stronger immune response than those receiving vaccines later in adolescence due to changes in the immune system after this age.

  • These diseases are serious, can be life-threatening, and can occur during adolescence and adulthood.
  • Even if your child has been vaccinated against diphtheria and tetanus (Td), they should still be vaccinated with dTpa vaccine to provide protection against whooping cough as well.
  • There is no minimum waiting period between previously administered tetanus/diphtheria (Td) vaccines and dTpa.

Can these vaccines have side effects?

Like all medications, vaccines may have side effects, but these are usually mild and temporary and do not lead to any long-term problems. If a reaction is severe or persistent, or if you are worried, contact your doctor or hospital as soon as possible.

Common side effects that may occur include fever; mild headache, feeling unwell, discomfort, redness, pain or swelling at the injection site.

Serious side effects, such as severe allergic reaction, are extremely rare.

Less common side effects are chills, diarrhea, nausea, body aches, decreased energy and sore or swollen joints.

The current dTpa vaccine is different from the vaccine offered when your child was of preschool age and adverse reactions are less common.

If your child has a reaction after vaccination you should:

  1. put a cold damp cloth on the area to relieve the pain if your child complains of tenderness at the injection site.
  2. give paracetamol (as per directions) only if pain and fever are present.
  3. contact your local doctor or seek medical attention if your child has an unexpected reaction that you are concerned about
  4. provide feedback to us via Smartvax SMS we will send to you 7 days after immunisation.

To get more information:

School Immunisation Program clinics are provided by a team of specially trained registered nurses.

A completed consent form MUST be submitted for a student to be vaccinated. After both the parent/legal guardian and student have read the information provided, please complete the consent form, select YES to vaccination in the consent section below and select submit for the form to be processed.

If you do not wish your child to be vaccinated through the school program, select No to vaccination. If you select No, please indicate why your child is not receiving the vaccination.

If you do not submit an immunisation form, you may be contacted by the Gold Coast Public Health immunisation team to check that you have been offered the opportunity for your child to participate in the free program. The Public Health Act 2005 authorises school principals to disclose student and parent information to Gold Coast Health, the school immunisation provider, so they can follow up with the parents/legal guardians of students who do not return a consent form.

The Information Privacy Act 2009 sets out the rules for collection and handling of personal information contained in the School.

As part of participation in the School Immunisation Program, Queensland Health collects details such as the student’s name, contact information, Medicare number and relevant health information. We also need to collect contact details for the parent or legal guardian of the student. This information is needed to correctly deliver vaccinations and to record vaccination details on the Australian Immunisation Register (AIR).

Authorised Queensland Health staff and Vaccine Service Providers (currently Smartvax) registered with Queensland Health may access your information for the purpose of clinical follow-up or disease prevention, control and monitoring. You may be sent an SMS from Smartvax asking about your child’s response to their vaccine as part of our vaccine monitoring. Your information will not be accessed by or given to any other person or organisation without your permission unless permitted or required by law.

The Australian Immunisation Register (AIR), previously known as the Australian Childhood Immunisation Register, was established in 1996 and is a national register of vaccinations of people who live in Australia.

The immunisation record will be sent to and kept by AIR, which is run by the Department of Human Services.

For information about how the Gold Coast Health protects your personal information, or to learn about your right to access your own personal information, see the Privacy Plan on the health service’s website www.goldcoast.health.qld.gov.au.

You can obtain your child's immunisation statement if they are younger than 14 years by using your Medicare online account through myGov or the Express Plus Medicare mobile app. The AIR privacy policy requires anyone 14 years or older to get their own statement. They can use their own Medicare online account through myGov. Alternatively, you or your child can call AIR enquiries line on 1800 653 809 and request a statement to be sent.

If you are unable to access all immunisation records via AIR you may be able to search missing immunisation records by completing and submitting an Immunisation Records Request online. www.goldcoast.health.qld.gov.au/immunisegc

    To do this I understand I must:

  • send a signed written request of the change via email to admin.immuniseGC@health.qld.gov.au (please phone the team on 1800 940 750 to confirm that your email has been received); or
  • send written request of the change with my child to present to the immunisation team on the day of the school clinic;
  • I may need to meet in person with the school immunisation team to confirm that changes to my child's consent have been received if the change is made on the day of vaccination.

Please be aware that by consenting to HPV vaccine your child will need to attend two school clinics that will be at least 6 months apart. If your child moves schools between clinics you will need to notify us of the school change.

Human papillomavirus (HPV) vaccine (two doses) *

 

Diphtheria-tetanus-pertussis (dTpa) vaccine (1 dose) *


Only students with a completed consent form that confirms "Yes" consent to one or both vaccines will be immunised.

Form submission

If you have missed any required fields, you will be asked to complete these fields (marked in red) before the form can be processed.

When you submit this consent form you will see a summary of the information submitted to indicate it has been received.  Please print a copy for your information. You will also be sent an email to the address you have listed above, to confirm your form has been received. If you do not see the consent summary or receive an email confirm receipt of this consent form please contact us so that we can check if the form has been received.

If you need to update any details on submitted forms please contact the Gold Coast Public Health on 1800 940 750 or email admin.immunisegc@health.qld.gov.au

Please press the submit button below to finish your consent submission.


Please wait while the form is processed. Do not press submit again or close the webpage during this time.

Last updated: 20 February 2020