Menactra Vaccine Consent form - Grey Bruce Health Unit

WHAT IS MENINGOCOCCAL DISEASE?Meningococcal disease is caused by bacteria. Thebacteria results in meningitis (infection of the liningof the brain and spinal cord) or septicaemia (a veryserious blood infection).Meningococcal disease can lead to severecomplications such as limb amputations, hearingloss and brain damage. Healthy people maybecome infected.Symptoms of meningococcal disease includesudden onset of high fever, severe headache, stiffneck, nausea, vomiting, rash, sleepiness, confusionand, in severe cases, coma, or death may also occur.HOW CAN YOU GET MENINGOCOCAL?Meningococcal disease is spread through dropletsfrom the nose and throat of an infected person. Itcan be spread by sharing eating utensils, waterbottles, food, musical instruments and kissing.Many people who have Meningococcal disease maynot show any signs or symptoms. They can pass thedisease to others and not know it.IS THERE A CURE?Antibiotics are used for the treatment of bacterialmeningococcal disease. Prior to the availability ofantibiotics, almost 100% of patients presenting withmeningococcal meningitis and septicaemia died.However, even with appropriate treatment, 10% ofcases will be fatal. Vaccination withmeningococcal ACYW-135 will prevent some typesof infections.PROTECTION FOR STUDENTSThe Ministry of Health and Long Term Care, offersa publicly funded Meningococcal immunizationprogram for all grade 7 students in Ontario.Meningococcal vaccination protects against some ofthe most common strains of the meningococcalvirus. One dose of the Meningococcal vaccine isrequired to ensure maximum protection.HOW CAN MY CHILD RECEIVEMENINGOCOCCAL VACCINE?Discuss the vaccine with your child. Complete theconsent form on the back of this page and clearlyindicate “yes” or “no” to the vaccine. Send this form tothe school with your child. A nurse will visit theschool to offer the vaccine to consenting students.IS THE VACCINE SAFE?The vaccine is safe.The vaccine may cause minor side effects such astenderness, redness and swelling at the injection site.Fever, headache, fatigue, muscle aches and nauseararely occur as a result of the vaccine.More serious reactions such as hives, trouble breathingor swelling of the face or mouth are extremely rare.Most instances begin within 30 minutes after injectionof the vaccine. The student will be closely observed forany reaction to the vaccine.The risk of getting meningococcal disease is muchgreater than the risk from the vaccine.WHO SHOULD NOT RECEIVE THE VACCINE?Students who have: An allergy to diphtheria toxoid or latex. A history of Guillain-Barré Syndrome (GBS)WHY SHOULD STUDENTS HAVEMENINGOCCAL IMMUNIZATION?Meningococcal immunization provides protectionagainst meningitis and septicemia. These diseases canbe very serious if not treated promptly.For any questions aboutMeningococcal A,C,Y,W-135 immunizationprogram, please contact Grey Bruce Health Unit519-376-9420 or 1-800-263-3456

Consent for Meningococcal ImmunizationStudent’s Name: Last ________________________ First _________________ Sex: male/femaleBirth Date: __________________year month daySchool:__________________ Ontario Health Card #: _____________Student’s Health HistoryDoes the student:Have any serious medical conditions?Take over-the-counter or prescription medications?Have allergies to latex or diphtheria toxoid?Have a history of Guillain-Barré Syndrome (GBS)?Received Meningococcal Vaccine previously?If yes, provide date(s) and name of vaccineAre you feeling well today? (Ask on day of clinic)NoYes,If Yes, provide detailsDate(s) administered:Name of vaccine:YES.I have read or had explained to me the informationabout this vaccine. I understand the benefits, sideeffects and risks. I consent for the student to receivethe Meningococcal vaccine.Parent/Guardian/Student Signature: ____________(in ink)Date:Phone: Home: ____________ Alt.#: ___________NO.I have read or had explained to me the informationabout this vaccine. I understand the benefits, sideeffects and risks. I DO NOT consent for the studentto receive the Meningococcal vaccine.Parent/Guardian/Student Signature: _____________(in ink)Date:Phone: Home: _____________ Alt.#: ___________FOR NURSE’S USE ONLYMenactra ®0.5 mL IMDate and Time Site Lot # Nurses SignatureRight deltoidLeft deltoidComments: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 inaccordance 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.3and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. Any questions regardingthis 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