Consent Form
Tdap Student’s Vaccination
اﻟﺤﻜﻮﻣﻴﺔ
DTP, DTaP, DT, or Td
38
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...............................................................................................................................
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+974 44070824 / +974 44070156
cdc@moph.gov.qa
:()ﻟﻠﻤﺪارس اﻟﺤﻜﻮﻣﻴﺔ SHSP@phcc.gov.qa
+974 50106491 : ﺟﻮال،+974cdc@moph.gov.qa
40271424 :ﺗﻠﻔﻮن
aalsahory@phcc.gov.qa
Consent
Consent Form
Form
Tdap Vaccine Campaign for Grade
Tdap Student’s Vaccine ................................ students
................
Student Name:.............................................................. َQID No.: .................................................... Date Of Birth:...........................................
School Name: ....................................................................................................................................... Class: ......................................................
Dear
Dear Parents
Parents,,
Ministry of Public Health in collaboration with Primary Health Care Corporation and Ministry of Education & Higher Education are
Ministry of Public Health in collaboration with Primary Health Care Corporation and Ministry of Education & Higher Education are
conducting
conducting thetheyearly
yearlyvaccination campaign
vaccination against
campaign Tetanus
against ,, Diphtheria
Diphtheria
Tetanus, and A
and
Diphtheria A cellular
cellular
and Pertussis
A cellular (Tdap) (Tdap)
Pertussis for Grade
for10 students
............
Students inin all
Studentsall
governmental andPrivate
in all Independent
Independent and Private schools
and Private ininQatar.
schools
schools Oatar.
in Qatar.
Your
Your son/daughter
son/daughter may
mayhave
havereceived
receivedvaccination against
vaccination these
against diseases
these in infancy
diseases and and
in infancy childhood. However,
childhood. sincesince
However, immunity to these
immunity to
vaccinations may decrease
these vaccinations over time
may decrease a booster
over dose is dose
time a booster highlyisrecommended by Ministry
highly recommended of PublicofHealth.
by Ministry Public Health.
The
The vaccine
vaccine is
is safe
safe,, effective
effective and
and routinely
routinely given
given to
to adolescents,
adolescents, adults
adults,, health
health care
care workers
workers and
and pregnant
pregnant women
women inin Qatar.
Qatar. Most
Most
people have
haveno noserious
seriousside
sideeffects from
effects Tdap
from Tdapvaccines. Injections
vaccines. are given
Injections into ainto
are given muscle in the upper
a muscle in the arm. This
upper mayThis
arm. cause soreness
may cause
soreness for a day or two, redness or swelling at the injection site
for a day or two, redness or swelling at the injection site or mild fever. or mild fever.
Vaccine Contraindications:
1. Anyone who has had a severe reaction to a previous dose of DTP, DTaP, DT, or Td should not get Tdap.
2. Fever higher than 38ºC on the day of vaccination.
3. Any neurological disorder like epilepsy ,convulsions, encephalitis.
4. Previous history of Guillain-Barré Syndrome.
(A) Does the student have any medical conditions? YES NO
If Yes Describe : ......................................................................................................................................
(B) Has the student ever had any allergic reactions to vaccinations? YES NO
If Yes Describe : ......................................................................................................................................
(C) Has your child previously received vaccination against Tetanus,Diphtheria,
YES NO
Pertussis vaccine in the last 5 years?
If yes, please provide a copy of your child’s previous vaccination card.
Parent’s Consent
Please mark one clearly: Agree to receive Tdap vaccine. Disagree to receive Tdap vaccine.
If you disagree, please state the reason ........................................................................................................................................................
Parent’s name and signature……………………....................…...…… Contact no.………...............……… Date …..…......................
OFFICE USE ONLY :
Signature of vaccine provider………....................……………….......................…… Date of vaccination .........................................
For any questions or concerns please contact HP & CDC, Ministry of Public Health:
Contact Number: +974 44070824 / +974 44070156
Email:
Schoolcdc@moph.gov.qa
Health at PHCC
Contact No. Tel: Email: SHSP@phcc.gov.qa
School Health at PHCC (Government School):
Email:cdc@moph.gov.qa
Contact Number: Tele: +974 40271424, Mob: +974 50106491
Email: aalsahory@phcc.gov.qa
