consent form - Fraser Health Authority

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.