MMR - HSE

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MMR - HSE
For official use only
Class: _________________ School Roll Number: _________________ Client ID: ___________________
Measles, Mumps, Rubella (MMR) and Diphtheria, Polio, Tetanus, Whooping Cough (Pertussis) (4 in 1) Vaccination Consent Form
If you wish to give consent please fill in Parts 1, 2 & 3. If you do not wish to give consent please fill in parts 1 & 4. (Parts 3 & 4 are overleaf).
Please note only a parent or legal guardian can consent or refuse consent for students.
Please fill in this form using a ballpoint pen. Return this completed form within the next 3 school days even if you do not consent.
Privacy Statement: HSE staff are aware of their obligation under the Data Protection Acts, 1988 and 2003.
The information provided will be included in an Immunisation Database. The HSE will use this information to validate clients,
monitor vaccination programmes and provide health care.
PART 1. Complete this part for all children (please use block capitals).
Child’s Forename: Child’s Surname (Family Name):
Child’s Middle Name: Otherwise known as:
Child’s Personal Public Services Number (PPSN):
(PPSN will be required to manage your immunisation record only)
Child’s Date of Birth (DD/MM/YYYY): _____/_____/_____
Mother’s Maiden Name:
Child’s Gender (circle as appropriate): Male/Female
Mother’s Date of Birth (DD/MM/YYYY): _____/_____/_____
(This information may be required to manage your child’s immunisation services)
Child’s Address:
County:
Child’s Surname at Birth :
Child’s Home Address at Birth:
Parent/Legal Guardian Forename and Surname:
Daytime Contact Phone Number:
Mobile Phone Number:
(By supplying your mobile phone number you are consenting to receive vaccine related texts)
School:
Class:
Teacher:
GP Name and Address:
(Your information may be shared with your General Practitioner)
PART 2. Complete this part with details of the child being vaccinated.
Is this your childs first year in Junior Infants?
Yes
No
Has this child received their routine vaccines due at 2, 4 and 6 months?
Yes
No
Do not know
Has this child received their first MMR vaccine due at 12 months?
Yes
No
Do not know
Has this child had any vaccines in the past 6 months?
Yes
No
Do not know
Please detail
Has this child had any serious illness? Yes
No
Yes
No
Has this child ever had a severe reaction to anything including medication or vaccines (including anaphylaxis)? Yes
No
Please detail
Is this child currently taking medication? (Include ointments/creams that affect the immune system e.g. Protopic cream)
Please detail
Please detail
Does this child have any illness or condition that increases their risk of bleeding? Yes
No
Please detail
09/16
Please turn over
PART 3. Please sign these boxes to say Yes.
Sign this box if you wish to give consent for MMR
Sign this box if you wish to give consent for 4 in 1
Yes, I consent to have the above named child
vaccinated to protect against Measles, Mumps and
Rubella (MMR).
Yes, I consent to have the above named child
vaccinated to protect against Diphtheria, Polio
Tetanus and Whooping Cough (4 in 1).
I have read and understand the accompanying vaccine
information, including known side effects. I confirm by
signing this form that I am authorised to give consent
on behalf of the above named child.
I have read and understand the accompanying vaccine
information, including known side effects. I confirm by
signing this form that I am authorised to give consent
on behalf of the above named child.
Signature: _____________________________
___________
Signature: _____________________________
___________
My Name (Please print): ___________________________
My Name (Please print): ___________________________
Date ______/______/______ (DD/MM/YYYY)
Date ______/______/______ (DD/MM/YYYY)
(Parent/Legal Guardian)
Yes
(Parent/Legal Guardian)
Yes
PART 4. Please sign these boxes to say No.
Sign this box if you do
not wish to give consent for MMR
Sign this box if you do
not wish to give consent for 4 in 1
No, I do not consent to have the above named child
vaccinated to protect against Measles, Mumps and
Rubella (MMR).
I have read and understand the accompanying vaccine
information, including risks of not vaccinating. I confirm
by signing this form that I am authorised to refuse
consent on behalf of the above named child.
No, I do not consent to have the above named child
vaccinated to protect against Diphtheria, Polio,
Tetanus and Whooping Cough (4 in 1).
I have read and understand the accompanying vaccine
information, including risks of not vaccinating. I confirm
by signing this form that I am authorised to refuse
consent on behalf of the above named child.
Signature: _____________________________
___________
Signature: _____________________________
___________
My Name (Please print): ___________________________
My Name (Please print): ___________________________
Date ______/______/______ (DD/MM/YYYY)
Date ______/______/______ (DD/MM/YYYY)
Reason for refusal: _______________________________
Reason for refusal: ______________________________
(Parent/Legal Guardian)
No
(Parent/Legal Guardian)
No
For official use only
If vaccine not administered please state why? Absent
Referred to hospital setting
Refused
Contraindicated
Deferred
DNA
Other _______________________________________________________________
Completed by: _______________________ MCRN/PIN: ___________ Date (DD/MM/YYYY): ______/______/______
(If applicable)
Administration Details:
Date
Given
Vaccine
Type
Vaccine Name &
Batch Number
Dose
Injection Site
Prescriber signature Vaccinator signature
& MCRN/PIN
& PIN/MCRN
(circle as appropriate)
/ /
/ /
MMR
4 in 1
Right Deltoid
(circle as appropriate)
School/Clinic
Left Deltoid
Clinic Name
(circle as appropriate)
(circle as appropriate)
Right Deltoid
Left Deltoid
Comments/Notes (For official use only)
Time MMR vaccine given ______: ______ am/pm Time 4 in 1 vaccine given ______: ______ am/pm
09/16
Vaccination location
School/Clinic
Clinic Name

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