MMR vaccine: consent form - English version - HE2597
Consent form in English for vaccination against mumps, measles and rubella (MMR), including information for parents and guardians.
The full resource:
Measles, mumps and rubella: Special Immunisation Programme
Protect your child now against measles, mumps and rubellaPlease sign and return the form to school.
MMR Vaccine Consent FormMany young people missed out on measles, mumps and rubella immunisation as children. To stop future outbreaks, students are being offered a FREE vaccine at school to help protect them against measles, mumps and rubella.
This form gives you information about the measles, mumps and rubella (MMR) vaccine and seeks your permission for your child to be immunised at school.
This form has two sections. The first is an information section for you to read and keep. The second section is the consent form, which needs to be filled out and returned to the school.
What are measles, mumps & rubella?Measles is a very infectious virus. Before immunisation was introduced, nearly all children caught measles. Measles causes a rash, high fever, runny nose, cough and sore watery eyes. Severe cases can result in pneumonia, encephalitis (swelling in the brain), diarrhoea and rarely, death.
Mumps is caused by a virus and is spread through the air. Mumps causes fever, headache and swelling of the glands around the face. In males mumps can cause swelling of the testicles and in rare cases, infertility. Mumps can also cause meningitis and encephalitis (swelling in the brain).
Unimmunised children exposed to measles or mumps need to be kept home from school for up to a month.
Rubella is usually a mild, viral illness. It causes a rash, fever and swollen glands in children. It is extremely dangerous for pregnant women because it can cause deafness, blindness and brain damage in an unborn baby.
How can your child be protected?The best protection is two doses of the MMR vaccine which protects against measles, mumps and rubella. It works by causing the body to make antibodies that fight these diseases.
If an immunised person comes into contact with any of these diseases, the antibodies in their blood will fight these viruses and help protect against being infected.
You need two doses of MMR to be protected
How well does the MMR vaccine work?Two doses of MMR will protect 99% of people against measles and rubella, and around 85% of people from mumps. A small number of people who are immunised may still become ill. If that happens, they usually get a milder illness than people who have not been immunised.
How safe is the vaccine?The MMR vaccine has an excellent safety record and has been used in New Zealand since 1990. For a list of possible reactions, see the common reactions section.
Who needs to be vaccinated?If you’re not sure whether your child has had two doses of MMR, the Ministry of Health recommends they get vaccinated. There are no additional safety concerns with having extra doses.
Most young people will have been given at least one dose of MMR in early childhood. However, changes to the Immunisation Schedule in 2001 and less effective reminder systems before 2005 mean that many teenagers and young adults are not fully protected.
If you have come from overseas, including the Pacific Islands, you may have had different vaccines that may not protect you against measles, mumps and rubella.
If you’re not sure or can’t find records, the Ministry of Health recommends having the MMR vaccine now.
Who shouldn’t be immunised?There are very few children who shouldn’t be immunised. Talk to your doctor, specialist or nurse before signing this form if your child:
- has had a serious reaction to a vaccine in the past
- is being treated for cancer or other severe illness
- has had a blood transfusion or other blood products in the last year.
Children with asthma or allergies, or who are recovering from an illness such as the common cold can still be immunised.
How is the vaccine given?The MMR vaccine is given as an injection in the upper arm. Up to two doses are being offered in school. Your school will let you know when it’s time to have the second dose.
Where else can I go to get my child immunised?MMR immunisation is also available free from family doctors, some pharmacists (if you’re 16 or older), and local health centres. If you change your mind about whether your child should receive MMR vaccine at school, please contact the school nurse directly.
Help stop measles, mumps and rubella outbreaks in our community - fill out and return the consent form to school today!
Common reactionsAs with any immunisation, your child may have a sore arm and get redness, pain or swelling at the injection site.
Fewer than one in ten children may experience a mild response between 5 and 12 days after immunisation, such as mild fever, a rash or swollen glands.
Other reactions that can occur, usually within one or two days, include:
- a fever (feeling hot)
- nausea (feeling sick)
- fainting, dizziness (light-headedness); having a good breakfast or lunch before immunisation can prevent fainting or dizziness
- general discomfort (feeling unwell, aches and pains).
The vaccinator will also give your child advice about what to do after the immunisation. Information about other rare reactions is available online at www.medsafe.govt.nz.
The chance of your child having a serious side effect is very much less than the chance of your child having a permanent injury from the diseases.
If your child has any unusual or severe symptoms after being vaccinated please contact your family doctor or public health nurse. You can also call Healthline free on 0800 611 116 anytime, 24 hours a day, 7 days a week. Health professionals should report reactions that happen after immunisation to the Centre for Adverse Reactions Monitoring (CARM). You can also report them directly through the CARM website (www.otago.ac.nz/carm).
Immunise at school or at your local GP
Where can I get more information?
- Speak to your family doctor or practice nurse
- Visit http://www.health.govt.nz/immunisation
- For technical information about the vaccine, search www.medsafe.govt.nz for “MMR” or “Priorix”
- Freephone 0800 IMMUNE (0800 466 863)
- Contact the school nurse directly if you would like more information about completing the Parent Consent Form or if you would like this information in another language.
Consumer rightsThe Code of Health and Disability Services Consumers’ Rights applies to all health and disability services in New Zealand. For more information, visit http://www.hdc.org.nz or call 0800 555 050.
PrivacySchools may have provided some information such as students’ names, room numbers, dates of birth, addresses and ethnicities. Your school should have let you know before doing this. This information, together with the information you give on the Parent Consent Form, is used to help run this immunisation programme. Information from the consent form and details of each immunisation given or declined (turned down) will be recorded by your district health board. Some information will be passed to the National Immunisation Register.
The National Immunisation Register is a national database, held by the Ministry of Health, which records immunisations given in New Zealand.
This information 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 this, contact your public health nurse, doctor or health centre.
Public health nurses will use this information:
- 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 inform the school of whether or not your child was immunised
- to help assess this immunisation programme and plan future programmes, or
- to refer your child to your family doctor or practice nurse 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 district health board’s privacy policies. If you have any questions about privacy, you can email firstname.lastname@example.org or contact the Privacy Commissioner’s free helpline on 0800 803 909.