Menactra Vaccine Consent form - Grey Bruce Health Unit

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