Protect against tetanus, diphtheria and whooping cough - consent form - NIP8903

November 2023
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School consent form for parents and guardians, which explains about immunisation with Boostrix to boost their protection against tetanus, diphtheria and whooping cough (pertussis).

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November 2023
November 2023
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The Boostrix vaccine is FREE and recommended for rangatahi (young people) from 11 years old. It’s a booster for protection against tetanus, diphtheria, and whooping cough (pertussis).

This form has two sections

  1. Information about immunisation
  2. A consent form for you to fill out and return to school.

What does the vaccine protect you from?

Tetanus is a rare but serious disease is caused by bacteria found in soil and manure (horse or cow poo). You can get the disease if dirt carrying this bacteria gets into a wound. These types of wounds can be caused by injuries sustained when mountain biking, skateboarding or other injuries when dirt may get into the wound.

Tetanus toxins caused by the bacteria act like a poison in your body. Symptoms of tetanus disease include painful muscle spasms, and difficulty breathing, chewing and swallowing. In the past, about 1 in 10 people who got tetanus would die from the disease.

Tetanus cannot be spread from person to person. Since we began immunising against tetanus in New Zealand it has become a very rare disease. Almost all cases of tetanus have happened in unvaccinated people.

Diphtheria is a serious disease that can easily spread from person to person (especially within families) through coughing and sneezing.

It causes a skin infection but can also affect the throat causing breathing difficulties.

Diphtheria was a common cause of death in children until the 1940s, but this disease is now very rare in New Zealand because of immunisation.

Whooping cough (pertussis) is a bacteria that causes breathing difficulties and severe coughing fits. The cough can go on for weeks or months which is why it’s sometimes called the ‘100 day cough’.

Having severe whooping cough can lead to pneumonia, seizures, and other neurological (brain) issues. More than half of babies under 12 months old who catch it need to go to hospital, and up to 1 in 50 of these babies die.

It’s very contagious. It can easily spread between whānau members by coughing and sneezing. It can also spread quickly around early education centres and schools.

Whooping cough is not under control in New Zealand, and when outbreaks occur, it affects thousands of people.

Immunisation is your best protection

In New Zealand babies (at 6 weeks, 3 and 5 months old) and younger children (4 years old) are given vaccines to protect against tetanus, diphtheria and whooping cough. The vaccine works by causing the body’s immune system to produce its own protection against the diseases.

As tamariki get older, this protection wears off, so rangatahi (young people) need a Boostrix vaccine to boost their immunity. This FREE booster is also offered at age 45 years and 65 years of age if a booster has not already been given. To ensure the whole whānau is protected, it is important that everyone is up to date with their immunisations to protect those most vulnerable.

While Boostrix covers three diseases only one injection is required and is given into the upper arm.

What alternatives are there to having the immunisations at school?

If your rangatahi (young person) has missed out for any reason, they can easily catch up with a visit to your medical centre, vaccinator or healthcare provider. This is also an option if you would like to be with them when they get their vaccination.

Who shouldn’t be immunised?

There are very few people who shouldn’t be immunised. If your rangatahi (young person) has had a serious reaction to a vaccine in the past, you should talk to their doctor or healthcare provider before signing this consent form.


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Side effects and reactions

Like most medicines, vaccines can sometimes cause reactions. These are usually mild, and not everyone will get them. Mild reactions are normal and shows that your immune system is responding to the vaccine.

If you are going to have any reactions, they normally happen in the first few days after getting vaccinated.

What you may feel

What can help

Swelling and pain at the injection site (hard and sore to touch)

Heavy arm

Nausea (feeling sick)

Headache, aches and pains


Place a cold, wet cloth, or ice pack where the injection was given. Leave it on for a short time

Do not rub the injection site

Rarely, your child may have a high fever (over 39°C)


Remove layers of clothing.

Rest and drink plenty of fluids.

Give paracetamol or ibuprofen for relief of significant discomfort or high fever as instructed by your vaccinator or healthcare provider.

Allergic reactions

Serious allergic reactions (known as anaphylaxis) are extremely rare. Only about 1 in 1 million people will experience this. The vaccinator is well-trained and knows what to look for and can treat an allergic reaction quickly if it happens. Serious allergic reactions normally happen soon after the vaccine has been given. This is why people need to wait for up to 20 minutes after immunisation.

Tips to prepare for vaccination

  • Eating before and after will make you less likely to feel faint or dizzy.
  • Wear a loose shirt with short sleeves so the vaccinator can easily access the upper arm.
  • Tell the vaccinating team if you are feeling scared or anxious, they can help you with this. 
  • Take things easy after the immunisation as your arm might be a bit sore.


Where can I get more information?

Speak to the vaccinator, your doctor or healthcare provider.

  • Visit for more information about this immunisation, or
  • for general information about immunisation.

The vaccinator's contact details are on the front of this form. Contact them directly if you need help or more information to fill out this form.

Detailed information on the Boostrix vaccine is published on the Medsafe website: 

  • Boostrix (Tdap):


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Your rights

The Code of Health and Disability Services Consumers' Rights applies to all health and disability services in New Zealand. For more information, visit or call 0800 555 050.


Schools may have provided some information such as students’ names, room numbers, dates of birth, addresses and ethnicities. Your school should have notified you before doing so. This information, together with the information you provide on the school consent form, is used to help administer this immunisation programme.

Information from the consent form and details of each immunisation given or declined will be recorded on a patient management system held by your health district and some of it will be passed to the Aotearoa Immunisation Register.

Patient management systems are used by health districts to record health information. The Aotearoa Immunisation Register is a national database for recording all immunisations given to all people in New Zealand.

The information on the consent form, the patient management systems and the Aotearoa Immunisation Register is protected by the Health Information Privacy Code. Only authorised health professionals will see, use, or change it. However, you may see your child’s information and correct any details. If you would like to do so, contact your vaccinator or doctor or health centre.

Vaccinators will use the information on the consent form, the patient management system and the Aotearoa Immunisation Register:

  • to contact your doctor or health centre if they need to check which immunisations your child has already been given
  • if your child has any health concerns 
  • to help assess this immunisation programme and plan future programmes, or 
  • to refer your child to their health provider or another local health provider for the immunisation if they missed it at school.

Information that does not identify individuals may be used for research purposes or to plan new services.

For more information about school roll sharing, privacy and the use of information, see your health district’s privacy policies. If you have any questions about privacy, you can email or contact the Privacy Commissioner’s free helpline on 0800 803 909.

If you have any questions about the Aotearoa Immunisation Register or would like to request a copy of your immunisation details held in the Aotearoa Immunisation Register please speak to your healthcare provider or contact

Summary Consumer Medicine Information

Boostrix is a vaccine used for booster vaccinations against tetanus, diphtheria and whooping cough (pertussis). The Boostrix vaccine is sometimes called Tdap (tetanus/ diphtheria/acellular pertussis).

The active ingredients of Boostrix are non-infectious substances from tetanus and diphtheria bacteria and purified proteins from the pertussis bacteria. The vaccine cannot cause any of these diseases.

Each 0.5 ml dose of Boostrix contains 2.5Lf units of diphtheria toxoid, 5Lf units of tetanus toxoid and the pertussis antigens: 8 micrograms (mcg) of pertussis toxoid, 8 mcg of filamentous haemagglutinin and 2.5 mcg of pertactin.

Each 0.5 ml dose also contains tiny amounts of aluminium (as aluminium hydroxide and aluminium phosphate), sodium chloride and water. These ingredients are all commonly used in other medicines and vaccines.

Your child should not have the vaccine if they have an allergy to Boostrix or to any of its ingredients.

Your child can have their vaccination at a later date if they currently have a severe infection with a high temperature. Talk to your family doctor, vaccinator or practice nurse first.

Your child should not have the Boostrix vaccine if they:

  • have had blood clotting problems or problems with the nervous system following earlier immunisation against diphtheria and/or tetanus

  • have experienced an inflammation/disease in the brain, which occurred in the seven days following a previous vaccination with a whooping cough (pertussis) vaccine

  • have a neurological disorder that is not stable.

Common side effects may include a local reaction around the injection site, such as soreness, redness, swelling or bruising, and feeling generally unwell (fever, nausea, aches and pains).

Other adverse effects, such as allergic reactions, might rarely occur. These possible adverse effects are listed in the full Consumer Medicine Information and Datasheet available from Medsafe.

If there are any unusual or severe symptoms after receiving Boostrix, please contact your doctor or health care provider immediately.

If your child has any of the following conditions, please discuss the immunisation with your family doctor, practice nurse, or the vaccinator before consenting to it:

  • a bleeding disorder

  • an immune deficiency condition (eg, your child is HIV positive)

  • a brain disease or a disease of the central nervous system, such as epilepsy or a tendency to febrile convulsions (seizures/fits due to a high fever)

  • allergies to any other medicines or substances, such as dyes, foods and preservatives

  • a previous serious reaction after receiving another vaccine containing tetanus, diphtheria and/or pertussis

  • is receiving any other medication or vaccines

  • has never been given a vaccine for tetanus, diphtheria or pertussis or has not completed the full course of vaccinations for tetanus and diphtheria.

Boostrix is a prescription medicine. Medicines have benefits and risks. Talk to your family doctor, practice nurse, or the vaccinator to find out the benefits and risks of this vaccine.

Full consumer information is available from Medsafe

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