HPV Vaccine Consent form - Grey Bruce Health Unit

WHAT IS HUMAN PAPILLOMAVIRUS (HPV)?
Human Papillomavirus (HPV) is a common virus that
affects both females and males. HPV virus is a cause of
cervical cancer in women.
HPV is the most common sexually transmitted infection
in Canada. There are many different types of HPV.
Some types of HPV can cause diseases of the genital
area such as warts, lesions or precancerous cells.
HOW CAN YOU GET HPV?
HPV is spread through skin-to-skin genital contact.
Both males and females may be infected with HPV
virus. Many people who have HPV may not show any
signs or symptoms. This means that they can pass the
virus to others and not know it.
IS HPV COMMON?
Approximately 75% of Canadians will have at least one
HPV infection during their lifetime.
There are about 1,400 Canadian women diagnosed with
cervical cancer each year. It is the second most common
cancer in women aged 20 to 44.
IS THERE A CURE?
Currently there is no cure for HPV. Cervical cancer
requires surgery to remove HPV infected tissues as well
as radiation and/or chemotherapy, depending on the
advancement of the disease. Treatment of warts requires
surgical removal or destruction of the HPV infected
tissue by chemicals. Some people will die of cancers
caused by HPV infection.
PROTECTION FOR STUDENTS
The Ministry of Health and Long Term Care offers a
publicly funded HPV immunization program for all
Grade 8 females in Ontario. HPV vaccination protects
against the most common 4 strains of the HPV virus.
Three doses of HPV vaccine are given to ensure
maximum protection.
HOW CAN MY CHILD RECEIVE HPV
VACCINE?
Discuss the vaccine with your child. Complete the
consent form on the back of this page and clearly
indicate “yes” or “no” to the vaccine. Send this form to
the school with your child. A nurse will visit the school
to offer the vaccine to consenting students in Fall,
Winter and Spring.
IS THE VACCINE EFFECTIVE?
HPV vaccine is nearly 100% effective in protecting
women against four types of HPV: 6, 11, 16 and 18.
HPV types 16 and 18 cause about 70% of cervical
cancers.
HPV types 6 and 11 cause about 90% of genital
warts.
IS THE VACCINE SAFE?
The vaccine is safe.
The vaccine may cause minor side effects such as
redness, tenderness and swelling at the injection site.
Fever, nausea, dizziness and headaches rarely occur
as a result of the vaccine.
More serious reactions such as hives, trouble
breathing, or swelling of the face or mouth are
extremely rare. Most instances begin within 30
minutes after injection of the vaccine. The student
will be closely observed for any reaction to the
vaccine.
WHO SHOULD NOT HAVE THE VACCINE?
Students who:
Had an allergic reaction to a previous dose of
HPV vaccine.
Have an allergy to any of the ingredients in the
vaccine which include: yeast, aluminum,
sodium chloride, L-histidine, polysorbate or
sodium borate.
Are pregnant.
WHY SHOULD STUDENTS HAVE HPV
IMMUNIZATION?
HPV immunization provides protection for young
women against cervical cancer, vaginal cancer and
genital warts. These diseases can be very serious
and even deadly if not treated promptly.
For any questions about HPV immunization
program, please contact Grey Bruce Health Unit
519-376-9420 or 1-800-263-3456

Consent for HPV Immunization
Student’s Name: Last ________________________First_____________________ Sex: male/female
Birth Date: ________________ School:_______________ Ontario Health Card #: _________________
year month day
Student’s Health History
Does the student:
Have any serious medical conditions?
Take over-the-counter or prescription medications?
Have allergies to yeast, aluminium, sodium chloride,
L-histidine, polysobate or sodium borate?
Have a history of reaction(s) to any immunizations?
Received HPV vaccine previously?
If yes, provide date(s) and name of vaccine
Are you feeling well today? (Ask on day of clinic.)
No
Yes
If Yes, Provide details
Date(s) administered:
Name of Vaccine:
YES.
I have read or had explained to me the information
about this vaccine. I understand the benefits, side
effects and risks. I consent for the student to receive
the three-dose series of HPV vaccine.
Parent/Guardian/Student Signature:
(in ink)
Date: _______________
Phone: Home:____________ Alt.#: ____________
NO.
I have read or had explained to me the information
about this vaccine. I understand the benefits, side
effects and risks. I DO NOT consent for the student to
receive the three-dose series of HPV vaccine.
Parent/Guardian/Student Signature:
(in ink)
Date: _____________
Phone: Home: ___________ Alt.#: ______________
FOR NURSE’S USE ONLY
GARDASIL ® 0.5mL IM
Dose Date and Time Site Lot # Nurses Signature
# 1 Right deltoid
Left deltoid
# 2 Right deltoid
Left deltoid
#3 Right deltoid
Left deltoid
Comments:
This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O.1990, c.H.7 and will be retained, used, disclosed and disposed of in
accordance with the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health Information Protection Act, 2004, S.O.c.3
and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. Any questions regarding
this collection may be directed to the Director of Finance and Administration at 101 17 th Street East, Owen Sound, Ontario, N4K 0A5, (519)376-9420.
Revised July 2012