consent form - Fraser Health Authority

Fraser Health Public Health Offices200-205 Newport Drive, Port Moody BC 604/949-72002266 Wilson Avenue, Port Coquitlam BC 604/777-8700400-22470 Dewdney Trunk Rd., Maple Ridge BC 604/476-7000300-4946 Canada Way, Burnaby BC 604/918-7605537 Carnarvon Street, New Westminster BC 604/777-6740Cloverdale: 17536-58 Avenue Surrey BC 604/575-5100Guildford: 100-10233 153 Street, Surrey BC 604/587-4750Langley: 20389 Fraser Hwy., Langley BC 604/539-2900Newton: 200-7337 137 Street, Surrey BC 604/592-2000North Delta: 11245 84 Avenue, Delta BC 604/507-5400North Surrey: 220 10362 King George Hwy., Surrey BC 604/587-7900South Delta: 4470 Clarence Taylor Cres., Ladner BC 604/952-3550White Rock: 15476 Vine Avenue, White Rock BC 604/542-4000104 34194 Marshall Road, Abbotsford BC 604/864-3400Box 104, 7243 Pioneer Avenue, Agassiz BC 604/793-716045470 Menholm Avenue, Chilliwack BC 604/702-4900Box 176 444 Park Street, Hope BC 604/860-763032618 Logan Avenue, Mission BC 604/814-5500Personal information collected will be used to enable thehealth authority to update the student's immunizationrecord. Statistical information will then be provided to theMinistry of Health Services for review, planning andanalysis. The information will be used and disclosed inaccordance with the Freedom of Information andProtection of Privacy Act. If you have any questionsabout the collection and use of this personal informationcontact your local Public Health Nurse.Important MessageIt is important to discuss the following withyour public health nurse before getting thevaccine:• If your child has ever had a shock-likeallergic reaction (anaphylaxis) toanything*. Symptoms may include hives,wheezy breathing, or swelling of somepart of the body.*For details about product specific vaccinecomponents, speak with your public health nurse.Please Note:• It is recommended that parents and studentsdiscuss this consent for immunization.• If you have any questions, contact your localpublic health unit before signing the consent.• A record of your child’s hepatitis Bimmunization will be given to your childafter the second injection.Hepatitis BPrevention ProgramforGrade 6 StudentsPlease return this consent form to theschool right away. If you do NOT wishyour child to be immunized, print yourchild’s name and the word “Refused”and return the consent form to theschool.Print Shop #June 2007

Hepatitis B ImmunizationsAfter immunization, this section willbe returned to you for your personalhealth files.StudentName: ______________________Birthdate: ___________________(YYYY/MM/DD)Hepatitis B - Office Use Only1. ____________________(YYYY/MM/DD)2. ____________________(YYYY/MM/DD)Hepatitis B ImmunizationStudent’s Name: ____________________________________ Birthdate: _____________________(YYYY/MM/DD)Care Card Number: ________________________________ Phone Number: __________________School: _______________________________________________ Grade: _____Div: ___________ Student received hepatitis B vaccine previously? Dates: _________ / _________ / _________I have read or had explained to me the information about hepatitis B vaccine, and I believe Iunderstand its benefits, risks and side effects. I have had the opportunity to ask questions whichwere answered to my satisfaction. I request the above named be immunized against hepatitis B.Date: ______________(YYYY/MM/DD)Signature: _______________________________________________(Parent or Guardian)Site RA LA Site RA LA Office Use Only#1 _____________________ __________________________________ #2 ___________________ ______________________________________Date (YYYY/MM/DD) Lot #/Provider Date (YYYY/MM/DD) Lot #/Provider(Please sign and detach the entire Consent Form portion of this pamphlet and return it to the school)Dear Parent or Guardian,British Columbia has had a higher rate ofhepatitis B than any other Province in Canada.To protect your child, a Hepatitis BImmunization Program is available to studentsin grade six.With your permission, your child will receive 2separate hepatitis B injections over a 4-6 monthperiod during the school year.If you have signed consents for your child toreceive Meningococcal C and Varicella vaccine,these vaccines may be given at the same time.Studies have shown there is no increase in sideeffects or any decrease in effectiveness of thesevaccines when they are given at the same time.Facts about Hepatitis BHepatitis B is a virus that attacks the liver. Itcan cause permanent liver damage and scarring,and in some cases, even death. It is the numberone cause of liver cancer in the world.About half the people who get hepatitis B neverfeel sick and can spread the disease withoutknowing it. It can be spread by contact withblood or body fluids of an infected person.Hepatitis B can be spread from something assimple as a child being involved in a school yardfight or helping a friend bandage an openwound. An infected mother may pass thedisease to a newborn at birth. In B.C., most newcases are the result of sexual contact with aninfected person. It can also be spread byintravenous drug use.• Symptoms include tiredness, fever, lossof appetite, yellow skin and eyes(jaundice).• Symptoms may last for weeks ormonths.• Many people with hepatitis B do notknow they have it.• Most people recover from the disease.However, up to 10% of people who gethepatitis B become carriers. This meansthey can continue to spread the diseaseand can develop permanent liverdamage or even liver cancer.• It is not spread by sneezing, coughing,hugging or using the same dishes orcutlery.Why offer Hepatitis B Vaccine toMy Child?In B.C., most new cases occur in youngadulthood. Immunization is being offered toyour child’s grade to ensure students areprotected well before potential exposure to thedisease.Possible Vaccine ReactionsHepatitis B vaccine usually has no side effects.Your child may experience minor reactions suchas redness, warmth or swelling at the injectionsite, tiredness or slight fever lasting 1-2 days.More serious reactions, such as severe pain orswelling at the injection site, are very rare andshould be reported to your local health unit.With any vaccine or drug, there is a possibilityof a shock-like allergic reaction (anaphylaxis).This can be hives, wheezy breathing, or swellingof some part of the body. If this happens,particularly swelling around the throat, seekmedical attention immediately. Please alsoreport such reactions to the health unit.See back of pamphlet for an importantmessage before signing this consent.