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Meningococcal ACWY Vaccination Program consent form for Year 10 students

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 meningococcal ACWY vaccine is not the same vaccine as it provides broader protection against other meningococcal strains as well as giving boosted protection against meningococcal C.

This form should be completed to confirm that either you do, or do not, consent to your child being immunised as part of the School Immunisation Program. You will be asked to select your choice (Yes or No) in the consent section at the end of the form.

Required fields are marked with an asterisk (*).

Student Details
Child's legal last name (surname) *
Child's legal first name*
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

Parent/legal guardian/authorised carer details.

Relationship to the student listed on this form: *
Please read and use tick boxes below to indicate if you wish or do not wish your child to receive immunisation at school

About the School Immunisation Program vaccines

Meningococcal ACWY vaccine

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). Starting 2016, Queensland (and other Australian jurisdictions) noticed a substantial rise of meningococcal disease caused by meningococcal strains W and Y.

Meningococcal disease is a rare but severe infection that 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 of healthy people (in about 10%) 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 through the School Immunisation Program.

The Meningococcal ACWY Vaccination Program is designed to protect young people and 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.

Can these vaccines have side effects?

Like all medications, vaccines may have side effects but 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.

If your child has a reaction after vaccination you should?

  1. put a cold damp cloth on the area to relieve the pain if your child complains of tenderness at the injection site.
  2. give paracetamol (as per directions) only if pain and fever are present.
  3. contact your local doctor or seek medical attention if your child has an unexpected reaction that you are concerned about
  4. provide feedback to us via Smartvax SMS we will send to you 7 days after immunisation.

To get more information:

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

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 form 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.

If you do not submit an immunisation consent form, you may be contacted by the Gold Coast Public 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 school principals to disclose student and parent information to Gold Coast Health, the school immunisation provider, so they can follow up with the parents/legal guardians of students who do not return a consent form.

If your child can't be vaccinated at school you can take your child to a free community immunisation clinic run by Gold Coast Public Health Unit. No appointment is required. For clinic dates and times visit Alternatively, take your child to your local doctor - the vaccine is free however, you may be charged a doctor's consultation fee. When making an appointment, advise reception what vaccines are required so they can be ordered.

The Information Privacy Act 2009 sets out the rules for collection and handling of personal information contained in the School Immunisation Program vaccination consent card.

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. We also need to collect contact details for the parent or legal guardian of the student. This information is needed to correctly deliver vaccinations and to record vaccination details on the Australian Immunisation Register (AIR).

Authorised Queensland Health staff and Vaccine Service Providers (Smartvax) registered with Queensland Health may access your information for the purpose of clinical follow-up 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.

The Australian Immunisation Register (AIR), previously known as the Australian Childhood Immunisation Register, was established in 1996 and is a national register of vaccinations of people who live in Australia.

The immunisation record will be sent to and kept by AIR, which is run by the Department of Human Services.

For information about how the Gold Coast Health protects your personal information, or to learn about your right to access your own personal information, see the Privacy Plan on the health service’s website

You can obtain your child's immunisation statement if they are younger than 14 years by using your Medicare online account through myGov or the Express Plus Medicare mobile app. The AIR privacy policy requires anyone 14 years or older to get their own statement. They can use their own Medicare online account through myGov. Alternatively, you or your child can call AIR enquiries line on 1800 653 809 and request a statement to be sent.

If you are unable to access all immunisation records via AIR you may be able to search missing immunisation records by completing and submitting an Immunisation Records Request online.

To do this I understand I must:

  • send a signed written request of the change at least 24 hours prior to vaccination via email to (please phone the team on 1800 940 750 to confirm that your email has been received); or
  • send written request of the change with my child to present to the immunisation team on the day of the school clinic;
  • I may need to meet in person with the school immunisation team to confirm that changes to my child's consent have been received if the change is made on the day of vaccination.

Meningococcal ACWY vaccination * (1 dose)
I do not consent to Meningococcal ACWY vaccine because
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 specially trained immunisation program nurse 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.

Only students with a completed consent form that confirms "Yes" I consent will be immunised.

Form submission

If you have missed any required fields, you will be asked to complete these fields (marked in red) before the form can be processed.

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. You will also be sent an email to the address you have listed above, to confirm your form has been received. If you do not see the consent summary or receive an email confirm receipt of this consent form please contact us so that we can check if the form has been received.

If you need to update any details on submitted forms please contact the Gold Coast Public Health on 1800 940 750 or email

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

   Please wait while the form is processed. Do not press submit again or close the webpage during this time.

Last updated: 20 February 2020