Northumbria Healthcare

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1 SINGLE SIDED and all 3 leaves stapled left hand corner RTHUMBERLAND CHILD HEALTH CENTRE WOODHORN LANE ASHINGTON RTHUMBERLAND NE63 9JJ TELEPHONE: MOBILE: Dear Parent / Carer Re - Diphtheria, Tetanus and Polio Vaccination (Td/IPV) We are offering the opportunity for your child to receive the above vaccination in school during the autumn term. PLEASE COMPLETE THE ENCLOSED CONSENT FORM INDICATING CONSENT OR N CONSENT AND RETURN THE COMPLETED FORM TO SCHOOL. If you are unsure if your child has received this vaccination at your GP surgery / hospital please can you check with your surgery. If your child has recently received this vaccination at your GP surgery, please can you document the date in the space provided so we can update our records. Attached to this letter there is some basic introductory information which we hope you find useful. Please do not hesitate to contact us if you have any queries regarding this. Yours sincerely IMMUNISATION TEAM CHILD HEALTH Encs :

2 DOUBLED SIDED Tetanus, Diphtheria and Poliomyelitis Vaccination Consent Form Most children receive their first course of immunisation against tetanus, diphtheria and polio (Td/IPV) as a baby, usually at 2, 3 and 4 months old. This is followed by a preschool booster at around the age of 4 years. A further booster dose is strongly recommended before they leave school and is offered to all young people in Year 10 at High School. It is a single injection containing diphtheria, tetanus and inactivated polio vaccine. Arrangements are made to hold sessions in school and we would be grateful if you would complete the form below indicating whether you do or do not wish your son or daughter to be given a booster vaccination. PLEASE COMPLETE THIS FORM AND RETURN TO SCHOOL If you have any queries please contact or your School Nurse Full name of child : School attending : Home address: Postcode : Date of Birth: / / Contact Telephone Number : Home : Mobile: NHS number (if known): Ethnicity: GP practice name and address: Important Questions Has your child had a Tetanus, Diphtheria and Poliomyelitis vaccination in the last five years? If yes please give the date : / / (please contact your GP if you are unsure) Has your child had a SEVERE reaction to anything which needed urgent hospital treatment? Does your child have an illness or receive medicines or therapy which affects their immunity? Is your child on any medication? Does your child suffer from any allergies? If you are unsure of any of the above information please contact your G.P surgery to obtain full details I would like my child named above to receive the tetanus diphtheria & polio vaccination Signature I do not want my child named above to receive the tetanus diphtheria & polio vaccination Signature Name (please print) Date / / Name (please print) Date / /

3 FOR OFFICE USE ONLY Date Site of injection (please circle) Batch number/ expiry date Immuniser Location / / L arm R arm Date of attempted vaccination Reason for injection not given Post immunisation issues / adverse reactions Date Details Immuniser TES

4 DOUBLED SIDED Tetanus, Diphtheria and Polio Vaccine 2013/2104 This factsheet gives you information about the Td/IPV vaccine. The vaccine protects against the three different diseases tetanus, diphtheria and polio (with Inactivated Polio Vaccine). What is tetanus? Tetanus is a painful disease that affects the muscles and can cause breathing problems. It is caused when germs found in the soil and manure get into the body through open cuts or burns. Tetanus affects the nervous system and it can kill. What is diphtheria? Diphtheria is a serious disease that usually begins with a sore throat and can quickly cause breathing problems. It can damage the heart and nervous system, and in severe cases it can kill. What is polio? Polio is a virus that attacks the nervous system and can permanently paralyse the muscles. If it affects the chest muscles or the brain, polio can kill. Frequently asked questions about the Td/IPV Vaccine When, how and why is the Td/IPV booster given? To teenagers aged 13 to 18, as an injection in the upper arm. It boosts the protection teenagers were given as a child against tetanus (T) diphtheria (d) and polio (IPV inactivated polio vaccine). Are there any side effects? It is common to get some swelling and redness where the injection is given. Sometimes a small painless lump develops, but this usually disappears in a few weeks. More serious effects are rare but include fever, headache, dizziness, feeling sick and swollen glands. Paracetamol or Ibuprofen should be taken if unwell after the immunisation, instructions should be carefully followed and the correct dose for age given. If necessary, a second dose should be taken four to six hours later. If temperature is still high after the second dose, speak to a GP or call NHS Direct on Are there any reasons why I should not be immunised? There are very few teenagers who cannot be immunised. You should T have the vaccine if you have had a confirmed anaphylactic reaction to a previous vaccine, or a confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B (antibiotics used in vaccines). Are there any other immunisations needed at this age? When having the Td/IPV booster, it is a good idea to check with your family doctor that all other immunisations are up to date for example, MMR (measles, mumps and rubella), MenC and for some people, hepatitis B. It s particularly important to check that MMR immunisation is up to date because some teenagers have not had two doses of MMR. Will more boosters be needed in the future? Additional boosters of these vaccines will probably not be needed. However, extra doses of the vaccines will be needed if visiting certain countries. This can be checked with the nurse at the teenagers surgery.

5 What if my child wants the vaccination but, as their parents, we would rather they didn t have it? The nurse is able to give the vaccination if your child gives consent to it and understands the issues, however, we would prefer your consent as well. Please discuss any concerns with your doctor or nurse. Contact Details for School Nurses West Locality Haydon Bridge High Ponteland High Prudhoe High Queen Elizabeth s High The Priory Blyth Valley / Cramlington Locality Astley High Atkinson House Bede Academy The Blyth School Cramlington Hillcrest Cramlington Learning Village North Locality Barndale House Berwick High James Calvert Spence College Longridge Towers The Duchess s High The Grove Central Locality Ashington High Bedlingtonshire High Cleasewell Collingwood Kyloe House Northumberland Church of England Academy Nunnykirk Pupil Referral Unit St Benet Biscops The King Edward VI Alternative Formats If you would like a copy of this information in large print, another language, audio tape or other format please call the Contact Centre on Other sources of information NHS Direct NHS Choices NICE (National Institute for Health and Clinical Excellence) Patient Advice and Liaison Service (PALS) Freephone: Text: northoftynepals@nhct.nhs.uk General Enquiries PIN 578/V2 Review date: May 2014 This material is the copyright of the