Protect against most cancers caused by HPV - consent form - NIP8900
School consent form for parents and guardians, which explains about immunisation with HPV vaccine (Gardasil9) to protect against most cancers caused by HPV.
The PDF download available is editable.
Please note that orders are restricted to 1,000 forms.
The full resource:
HPV immunisation is FREE for rangatahi (young people) aged 9 to 26 years. HPV immunisation helps protect rangatahi against a number of cancers later in life.
This form has two sections
- Information about immunisation
- A consent form for you to fill out and return to school.
What does the vaccine protect you from?
Human papillomavirus (HPV) is a group of very common viruses that infect about 80% of people at some time in their lives. It’s passed on through intimate skin-on-skin contact. Most HPV infections get better on their own. But sometimes they can cause a number of diferent cancers for all genders later in life – such as cervical and throat cancer.
Immunisation is your best protection
The HPV vaccine is called Gardasil9. It is very effective at preventing nine types of HPV.
Most rangatahi (young people) are offered the vaccine at school, usually in Year 7 or 8. This is the best time to immunise them, as their immune system is really effective at making antibodies in response to the vaccine and protection is long lasting.
The vaccine is given as an injection in the upper arm. A second dose of HPV vaccine is given with a minimum interval of 6 months between the two doses.
How effective is the vaccine?
The HPV vaccine is very effective in preventing infection from the nine types of HPV responsible for around 90% of the cancers caused by HPV.
Protection is expected to be long-lasting. In studies, almost everyone who received the vaccine was protected against HPV infection and disease.
The number of HPV infections and diseases has fallen significantly among rangatahi (young people) in countries offering HPV immunisation, including New Zealand.
For this vaccine to be most effective people should be immunised before they are exposed to HPV.
Rangatahi aged 9 to 14 years need two doses.
Rangatahi (young people) also need to have all the recommended number of vaccine doses for their age. Those aged 14 years or younger need fewer doses (two instead of three) of the vaccine to be protected because they respond better to the vaccine than older people.
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, pharmacy or healthcare provider. This is also an option if you would like to be with them when they get their vaccination.
Delaying HPV vaccine may mean your child needs another dose to be protected, as people aged 15 years and older need three injections.
Who shouldn’t be immunised?
There are very few people who shouldn’t be immunised. If your child has had a serious reaction to a vaccine in the past, you should talk to their doctor, vaccinator or healthcare provider before signing this consent form.
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)
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.
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 immunise.health.nz/HPV for more information about these immunisations, or
- immunise.health.nz 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 HPV vaccine is published on the Medsafe website:
- HPV(Gardasil9): www.medsafe.govt.nz/consumers/cmi/b/boostrix.pdf
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 email@example.com 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 firstname.lastname@example.org
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).