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Annex A.
Notification Letter and Consent Form Template
Republika ng Pilipinas Rehiyon ___________
NOTIFICATION LETTER DATE: ________________ DIVISION: ________________________________ SCHOOL: _________________________________ ADDRESS: ________________________________ Dear Parent Guardian: This school as a Public Elementary / Secondary School will provide School-Based Immunization (SBI) of Measles-Rubella (MR) and Tetanus-Diphtheria (Td) vaccines to Grade 1 and Grade 7 students in coordination with the Department of Health (DOH) and the Local Government Unit (LGU). This Notification is being issued to you as information of the activity that will be conducted for SY 2024-2025. Should you have further questions/ clarifications on this matter, please get in touch with the Principal/ School Head. Thank you very much. Very truly yours, ____________________________________ Name of School Head/Principal
ACKNOWLEDGEMENT AND CONSENT
I have read and understood the information regarding the intended immunization services to be given to my child.
Date of Birth Name of the Child (mm/dd/yyyy) Surname: First Name: Middle Name: ---/---/---- Contact Information Age Sex Contact Number: School:
PRE-VACCINATION CHECKLIST (FOR PARENTS/GUARDIAN TO COMPLETE)
Your consent is required before your child can be immunized at school. Request clearance from your physician if any of the following applies (kindly check (✔) if any condition applies to your child): My child had a history of severe allergy to measles-containing or Td vaccines. My child has a severe illness: Primary immune-deficiency disease Suppressed immune response from medications Leukemia Lymphoma Other generalized malignancies None, my child is relatively healthy. CONSENT FOR IMMUNIZATION (Please check in the box provided) Yes, I will allow my child to be provided the immunization services as per DOH recommendation Grade 1 (MR. Td) Grade 7 (MR. Td) No, I will not allow my child to receive the immunization service because __________________________________________________________________________. I understand that by opting out of the required immunizations, my child may be at a higher risk of contracting vaccine-preventable diseases. By signing this waiver, I acknowledge that I have read and understood the information provided above. I voluntarily chose to exempt my child from the required school immunizations.
___________________________________________ Name and Signature of Parent/Guardian Annex A. Notification Letter and Consent Form Template Republika ng Pilipinas Rehiyon ___________
NOTIFICATION LETTER DATE: ________________ DIVISION: ________________________________ SCHOOL: _________________________________ ADDRESS: ________________________________ Dear Parent Guardian: This school as a Public Elementary / Secondary School will provide School-Based Immunization (SBI) of Human Papillomavirus (HPV) Vaccine to Grade 4 Female students in coordination with the Department of Health (DOH) and the Local Government Unit (LGU). This Notification is being issued to you as information of the activity that will be conducted for SY 2024-2025. Should you have further questions/ clarifications on this matter, please get in touch with the Principal/ School Head.
Thank you very much.
Very truly yours, ____________________________________ Name of School Head/Principal
ACKNOWLEDGEMENT AND COSENT
I have read and understood the information regarding the intended immunization services to be given to my child.
Date of Birth Name of the Child (mm/dd/yyyy) Surname: First Name: Middle Name: ---/---/---- Contact Information Age Sex Contact Number: School:
PRE-VACCINATION CHECKLIST (FOR PARENTS/GUARDIAN TO COMPLETE)
Your consent is required before your child can be immunized at school. Request clearance from your physician if any of the following applies (kindly check (✔) if any condition applies to your child): My child had a history of severe allergy to human papillomavirus (HPV) vaccine. My child has a severe illness: Primary immune-deficiency disease Suppressed immune response from medications Leukemia Lymphoma Other generalized malignancies None, my child is relatively healthy. CONSENT FOR IMMUNIZATION (Please check in the box provided) Yes, I will allow my child to be provided the immunization services as per DOH recommendation Grade 4 Female Student (human papillomavirus (HPV) vaccine) No, I will not allow my child to receive the immunization service because __________________________________________________________________________. I understand that by opting out of the required immunizations, my child may be at a higher risk of contracting vaccine-preventable diseases. By signing this waiver, I acknowledge that I have read and understood the information provided above. I voluntarily chose to exempt my child from the required school immunizations.
___________________________________________ Name and Signature of Parent/Guardian
