Immunise against HPV: Parent Consent Form - HE2044

Reviewed
December 2022
This resource relates to the following topics:

Consent form in English for vaccination against human papillomavirus (HPV), including information for parents and guardians.

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Reviewed
December 2022
Updated
December 2022
Format
Pamphlet A4
HE code
HE2044
Language
English

The full resource:

Immunise against HPV

(human papillomavirus)

In Year 7 or 8, students are offered free HPV immunisation to help protect them against a number of cancers later in life. It can save lives.

Parent consent form

Please sign and return the form to school.

HPV vaccine parent consent form

In Year 7 or 8, students are offered free HPV immunisation to help protect them against a number of cancers later in life. It can save lives.

This form provides you with information about the HPV vaccine and seeks your permission for your child to be immunised at school.

Please complete the attached consent form and return to your school.

What is HPV

HPV is a group of very common viruses that infect about 80% of people in their teenage years. HPV spreads through intimate skin-on-skin contact.

Most HPV infections get better on their own. But sometimes they can cause a number of different cancers for all genders later in life – such as cervical and throat cancer.

Getting the free HPV vaccine

The HPV vaccine is called Gardasil® 9. It is very effective at preventing nine types of HPV.

School vaccinations

Most tamariki are offered the vaccine at school, usually in Year 7 or 8. This is the best time to immunise them, as a pre-teen’s immune system is really effective at making antibodies in response to the vaccine and protection is long lasting.

Tamariki aged 9 to 14 need two doses

Immunisations outside of school

If your child has missed out for any reason, they can easily catch up with a visit to your medical centre or practice nurse. This is also an option if you would like to be with your child when they get their vaccination.

Side effects

 

The HPV vaccine has an excellent safety record but, like all medicines, it may cause side effects.

The most common side effect is a sore arm from the injection - you can put a cloth or ice pack on it to feel better.

Other common side effects include:

  • headache
  • feeling tired, dizzy, or sick
  • feeling feverish or sweaty.

Very rarely, a severe allergic reaction (anaphylaxis) can happen after a vaccination. Your child will be observed for 20 minutes after the immunisation so that any reaction can be treated. Vaccinating teams are trained to manage anaphylaxis and have the equipment for this.

Tamariki recovering from illnesses such as a cold, flu, or COVID-19 (after isolation) can still be immunised as long as they do not have a fever.

If your child has had a severe allergic reaction to a vaccine in the past, or has been unwell recently, please include these details on the consent form attached.

Tips for preparing your tamariki for vaccination

A good breakfast or lunch before immunisation can prevent your tamariki from feeling faint or dizzy. A snack before or after also helps.

The vaccinations are given in the upper arm, so wearing a loose shirt with short sleeves will make things easier.

Make sure they take things easy after their immunisation as their arm might be a bit sore.

Where can I get more information?

Contact the vaccinator directly if you would like more information about filling in the Parent Consent Form or if you would like this information in another language.

Summary Consumer Medicine Information

  • Gardasil®9 is a vaccine that helps prevent the following diseases caused by human papillomavirus (HPV) types 6, 11, 16, 18, 31, 33, 45, 52 and 58: cervical, vulvar, vaginal and anal cancer, abnormal and precancerous cervical, vulvar, vaginal, genital and anal lesions, genital warts, HPV infection and other HPV cancers.
  • Each 0.5 mL dose contains 30 micrograms (mcg) of HPV 6 L1 protein, 40 mcg of HPV 11 L1 protein, 60 mcg of HPV 16 L1 protein, 40 mcg of HPV 18 L1 protein, 20 mcg of HPV 31 L1 protein, 20 mcg of HPV 33 L1 protein, 20 mcg of HPV 45 L1 protein, 20 mcg of HPV 52 L1 protein, and 20 mcg of HPV 58 L1 protein.
  • Each 0.5 mL dose also contains sterile water and tiny amounts of aluminium, salt (sodium chloride), L-histidine, polysorbate 80, and sodium borate. These ingredients are all used commonly in other medicines and vaccines.
  • The vaccine does not contain preservatives, antibiotics, or any human or animal materials.
  • The vaccine is manufactured using yeast culture and may contain traces of yeast (Saccharomyces).
  • Your child should not have the vaccine if they have an allergy to Gardasil®9 or any of its ingredients.
  • The safety of Gardasil® 9 in pregnancy is unknown. Published data have not found any safety concerns among pregnant women who have been inadvertently vaccinated.
  • If your child has any of the following conditions, please discuss with the public health nurse, your doctor, specialist, or vaccinator before consenting to immunisation: any blood or bleeding diseases or a weakened immune system due, for example, to a genetic defect or Human immunodeficiency virus (HIV) infection.
  • Common reactions are listed overleaf. Other reactions might occur rarely. Reported adverse events are listed in the full Consumer Medicine Information and data sheet available from the Medsafe website.
  • If your child has any unusual or severe symptoms after receiving Gardasil®9, please contact your family doctor, specialist or the vaccinator. 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).

Further information is available from Medsafe: www.medsafe.govt.nz/consumers/cmi/g/gardasil9.pdf

Consumer rights

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

Privacy

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 Parent 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 by your health district, and some of it 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.

The 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 so, contact your vaccinator, nurse, doctor or health centre.

The vaccinator 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 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.

The National Screening Unit will use this information to support efforts to reduce cancer.

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 enquiries@privacy.org.nz or contact the Privacy Commissioner’s free helpline on 0800 803 909

 

Code: HE2044