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School Immunisation Program Consent form for Meningococcal ACWY Program

Required fields are marked with an asterisk (*).
Student Details
Date of Birth *
Gender *
Does your child identify as either Aboriginal or Torres Strait Islander?
If yes, please select
Is English your family's main language spoken at home?
Parent/Legal Guardian Details
Relationship to the student listed on this form: *
Consent for Immunisation: parent/legal guardian to read and acknowledge consent statements

Consent of a parent/legal guardian is needed before any student can be vaccinated. Only students with a completed consent form will be vaccinated.

Queensland Health’s School Immunisation Program is offering every Year 10 student in Queensland free immunisation against meningococcal ACWY and it is given as one injection. Your child would have received a Meningococcal C vaccine as an infant. The MenACWY vaccine is not the same vaccine as it provides broader protection against other meningococcal strains as well as giving boosted protection against Men C.

Meningococcal disease is a rare but severe infection that can cause death within 24 hours or profound life-long disability (brain damage, hearing loss, limb loss). In 2016, Queensland (and other Australian jurisdictions) experienced a substantial rise of meningococcal disease caused by meningococcal strains W and Y.

Meningococcal disease occurs when meningococcal bacteria invade the body from the throat or nose. Meningococcal bacteria are carried in the nose and throat of a small proportion (approximately 10%) of healthy people and are spread through close prolonged contact. The bacteria are more commonly found in teenagers and young adults. There are a number of different strains of meningococcal bacteria. Worldwide, the main strains that cause meningococcal disease are A, B, C, W and Y.

Most people with meningococcal infection fully recover, but some people who survive can develop long-term health complications including limb deformity, skin scarring, deafness and possible loss of brain function. Meningococcal W disease has a higher death rate than meningococcal C and meningococcal B infections and may be fatal in about 1 in 10 cases.

It is not easy to catch meningococcal disease. While the bacteria can be spread via droplets from the nose or throat during coughing and sneezing, close and prolonged contact with a person who has the bacteria in their nose or throat is usually needed for the bacteria to spread. For example, the disease is not spread by sharing cups, drinks or cigarettes. As meningococcal bacteria cannot live long outside of the body, the infection can also not be picked up from water supplies, swimming pools, bed linen or pillows.

After exposure to the bacteria, it usually takes from three to four days to become ill, although sometimes it can be as little as one day or as long as 10 days.

The symptoms of meningitis don’t appear in any particular order and may appear differently in different people. In older children and adults symptoms of meningitis can include headache, fever, vomiting, neck stiffness, drowsiness and confusion, and discomfort looking at bright lights. There may also be a rash, particularly with meningococcal meningitis where there is often a characteristic purplish-red rash which does not fade under pressure.

If anyone has the above symptoms, seek urgent medical attention. Early treatment can sometimes prevent serious complications.

Why are students vaccinated at this age?

Some types of meningococcal disease can be prevented with immunisation and these include meningococcal A, B, C, W, and Y. There is no single vaccine that provides protection against all strains of meningococcal disease.

Some of the highest rates of meningococcal carriage occur among 15 to 19 year olds and this age group can transmit the meningococcal bacteria to people who are at increased risk of infection, including young children. This program is offering free meningococcal ACWY vaccination to all Year 10 students in 2018 through the School Immunisation Program. The vaccine is also available free for teenagers 15 to 19 years at community immunisation clinics and GP practices until 31st May 2018.

The Meningococcal ACWY Vaccination Program is designed to protect young people and also reduce risks for the community as a whole by decreasing the proportion of people carrying the bacteria in their nose and throat.

Is the vaccine safe?

The meningococcal ACWY vaccine is safe and effective. Meningococcal ACWY vaccination programs targeting adolescents have been effectively implemented in the UK since 2015 and in the US since 2005.

The vaccine contains the antigens of four serogroups (A, C, W135 and Y) which are conjugated to a carrier protein. It also contains other additives in very small amounts to either assist the vaccine to work or to act as a preservative. Serious side effects from the vaccine are extremely rare. Minor side effects that may be experienced include tenderness, redness or swelling at the site of injection and, low grade fever.

School immunisation clinics are provided by a team of specially trained registered immunisation nurses.

To make sure all Year 10 students are offered the opportunity to participate, the Public Health Act 2005 authorises school principals to disclose student and parent information to the school immunisation provider so they can follow up with parents or legal guardians of students who do not return a consent form.

A completed consent form MUST be submitted for a student to be vaccinated. After both the parent/legal guardian and student have read the information provided, please complete the consent form, select YES to vaccination in the consent section below and select submit for the form to be processed.

If you do not wish your child to be vaccinated through the school program, select No to Vaccination. If you select ‘No’ please indicate why your child is not receiving the vaccination.

Your child will not be vaccinated without a completed consent form.

If you do not submit an immunisation consent form, you may be contacted by Gold Coast Health Immunisation team to check that you have been offered the opportunity for your child to participate in the free program. The Public Health Act 2005 authorises the school principal to provide your contact details to the school immunisation provider so they can follow up with the parents/legal guardians of students who don’t return a consent form.

If your child can’t be vaccinated at school or misses a dose at the school clinic your child can attend a catch-up session or you can take your child to your doctor or community immunisation clinic. The vaccine is free; however a doctor’s consultation fee may apply. When you call a GP practice for an appointment you should advise their receptionist what vaccination is required as they may need to order the vaccine.

The Information Privacy Act 2009 sets out the rules for collection and handling of personal information contained in the School Immunisation Program vaccination consent form. As part of participation in the School Immunisation Program, Queensland Health collects details such as the student’s name, contact information, Medicare number and relevant health information. Contact details for the parent or legal guardian of the student are also collected. This information is needed to correctly deliver vaccinations and to record vaccination details on Queensland Health’s immunisation database (Vaccination Information and Vaccination Administration System) and the Australian Immunisation Register (AIR).

Authorised Queensland Health staff and Vaccine Service Providers registered with Queensland Health may access your information for the purpose of recall, reminders, clinical follow up (currently Smartvax) or disease prevention, control and monitoring. Your information will not be accessed by or given to any other person or organisation without your permission unless permitted or required by law.

For information about how the Gold Coast Hospital and Health Service protects your personal information, or to learn about your right to access your own personal information, see the Gold Coast Hospital and Health Service’s Privacy Plan. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at On the day of vaccination, ensure your child has breakfast.

Once your child receives the vaccination they will be given a Record of Vaccination slip to take home. Advise your local doctor that the vaccination has been given the next time you visit. Please keep this Record of Vaccination in a safe place for future reference.

In future you can obtain a record of your child’s immunisation history from the Australian Immunisation Register (AIR) through the Department of Human Services. You will need to register online through, and then you will be able to review your child's vaccine history. Alternatively, you can call AIR on 1800 653 809 and request that a statement is sent to you. If you are unable to access immunisation records via AIR you may be able to access records of immunisations received on the Gold Coast through the School Immunisation Program by completing the online Vaccination History Request online via the Immunisation/Gold Coast website.

The MenACWY vaccine may cause mild reactions such as discomfort and/or rednesss at the inection site, headache, fatigue or a mild fever. Severe allergic reactions or other serious side effects are extremely rare.

If your child has a reaction after vaccination you should?

  1. Put a cold damp cloth on the area to relieve pain if your child complains of tenderness at the injection site.
  2. Only give paracetamol (as per directions) if pain and fever are present.
  3. If your child has an unexpected reaction that you are concerned about please contact Gold Coast Immunisation Team 1800 940 750, your local doctor or seek medical attention.

To get more information:

  • Contact Gold Coast Health Immunisation Team: phone 1800 940 750 or email:
  • Call 13 HEALTH (13 43 25 84)
  • Contact your doctor
  • Visit Queensland Health’s Immunisation website:
  • Visit the Immunise Australia website:

  • up to 2 business days before immunisation takes place at the school, I understand I need to do so by making a written request via email to Gold Coast Public Health Unit at
  • within 2 business days of immunisation, I understand that I need to send a signed written request of changes with my child to take to the school immunisation team or alternatively I need to meet in person with the school immunisation team to confirm that changes to my child's consent have been received
Meningococcal ACWY vaccination *

On the basis of the above consent statements,

for my child to receive a single dose of meningococcal ACWY vaccine.

Pre Immunisation Checklist
Please tick any boxes that apply to your child
If your child is immunocompromised please talk to your doctor about these vaccinations.

Prior to administering the vaccine(s), the nurse immuniser will ask the student if the information above needs to be updated. Please inform us of any changes as it may be many weeks between when you provide this information and when your child receives immunisation.

Form submission

When you submit this consent form you will see a summary of the information submitted to indicate it has been received.  Please print a copy for your information. If you need to update any details on submitted forms please contact us.

If you do not receive this consent summary please contact us so that we can check if the form has been received.  

If you have missed any required fields you will be asked to complete these fields before the form can be processed.

Our contact details: phone: 1800 940 750  email:

Please press the submit button below to finish your consent submission.

Last updated: 19 October 2018