Student influenza vaccine consent form 1Introduction2Consent3Contact details4Medical information You can use this form to: Provide Council with consent for a dose of the influenza vaccine to be administered to your child. FluQuadri/FluarixTetra/Afluria Quad contains 2 killed A and B strains in 2019. Before you begin: It takes about 5 minutes to complete this form and you will need to: Provide your child’s full name, date of birth and Medicare number Tell us your name, phone number, email address and registered Medicare address Read and accept the City of Boroondara Privacy Statement Read the Influenza Information on the Better Health Channel, which includes the pre-immunisation checklist and vaccine side effects After you complete this form we will: Send you an email confirming we have received your child's consent form We may contact you about your child's consent form, if required. What happens with your information? The information will be disclosed to the Department of Human Services, Australian Immunisation Register, a national register that records vaccinations given to all people of all ages in Australia The information may be disclosed to the State or Commonwealth Governments for monitoring purposes only We record your information on our customer databases and make it available to relevant Council staff in line with our Privacy Policy Personal and health information is being collected by the City of Boroondara for the purpose of receiving an Influenza vaccination. The information will be used by Council and its contracted service providers for that primary purpose or a directly related purpose and shall be disclosed to relevant Council staff and medical practitioners administering the vaccination. It will not otherwise be used or disclosed unless that use or disclosure is permitted or required by law. You may apply for access and/or amendment of the information by writing to Council’s Privacy Officer. I confirm that I have read and understood the information provided (via the links on the Introduction page of this form) to the BetterHealth Channel regarding the influenza immunisation, including the contraindications, risks and side effects. I understand that I am giving consent for my child to receive a dose of influenza vaccine. I have been given the opportunity to discuss the risks and benefits of vaccination with an immunisation provider. I understand that consent can be withdrawn at any time before vaccination takes place. I understand that it is recommended that all people who receive the influenza vaccine remain at the immunisation venue for 15 minutes.Consent * Required Yes, I have read the Influenza Information on the BetterHealth Channel and I consent to my child receiving the influenza vaccine I consent to the collection/use of mine and my child's information on this form. HiddenName of school * Required Student details * Required Child's given name Child's last name Child's date of birth * RequiredMust be dd/mm/yyyy format DD slash MM slash YYYY Gender * Required Male Female Other Parent or guardian details * Required Given name Family name Email address * Required Enter email Confirm email Primary phone number (mobile if applicable) * RequiredSecondary phone number (home)Residential address * Required Street address or PO Box Address line 2 Suburb / City Post code Does your child have a Medicare card? * RequiredThis helps for accurate reporting to the Australian Immunisation Register, a national register that records vaccinations given to all people of all ages in Australia. Yes No Please provide your Medicare card number * Required Medicare card individual reference number * Required Is your child of Aboriginal or Torres Strait Islander origin? * Required No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander Not disclosed EligibilityYour child is eligible for free vaccines in Victoria.Has your child previously been vaccinated against influenza? * Required Yes No Did your child experience any allergic reactions? * Required Yes No GP assessment alertIf your child has experienced an allergic reaction to a previous influenza vaccine, you should seek allergy advice before any further influenza vaccination. Please see your GP for further assessment.HiddenDoes your child have an anaphylactic allergy to eggs? * Required Yes No Does your child have a history of Guillian-Barré syndrome (severe muscle weakness)? * RequiredGuillain-Barré syndrome (GBS) is a rare autoimmune condition with acute onset of a rapidly progressive, ascending, symmetrical flaccid paralysis, with or without sensory loss. Yes No GP assessment alertVaccination is generally not recommended for people with a history of GBS who’s first episode occurred within 6 weeks of influenza vaccination. Please see your GP for further assessment.I have read and accept Council's Privacy Policy and understand how my information will be used. * Required Yes EmailThis field is for validation purposes and should be left unchanged.
