Letter to Grade 9 Families about Tetanus, Diphtheria and Acellular

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RIVER EAST AND TRANSCONA
845 RegentAvenueW
WinnipegMB R2C3A9
Tel: 204. 938. 5555
Fax: 204.938. 5296
February2016
Letter to Grade 9 Families about Tetanus, Diphtheria and Acellular Pertussis
(Tdap) Booster Vaccine for Grade Nine Students
*Please complete and returab^Februarv 10. 2016*
TheWinnipeg Regional Health Authority (WRHA) PublicHealthProgram offers a booster vaccine for
tetanus. diphtheria and acellular pertussis (Tdap vaccine) to all grade 9 students.
Vaccinescontainingtetanus, diphtheriaandpertussis aregivenasboostersatregularly scheduledtimes
to children and adults. The last early childhood immunization isgiven between the ages of4-6 years and
contains tetanus, diphtheria andacellular pertussis and polio. Your child may have also received Tdap or
teatanus andDiptheria(Td) vaccine if theyweretreated for a cutto the skin.
Wewill checkyourchild'simmunizationrecordsintheprovincialimmunizationregistryto seeifyour
child is due for teatanus, diphtheria, or pertussis.
Ifyour child hasreceived immunizations outside ofManitoba, please provide a copy ofthe record of
immunization withyour consent form sothatyour child's records may beupdated inthe provincial
immunization registry.
ThePublic Health Nurse will immunize students in school at a scheduled time inMarch or April.
After reading the attached fact sheet on Tdap vaccine, please:
complete and siguthe consent form, indicatingeither "yes I do consent" or "no I do not
consent", and
return it to the school by the date noted below.
A reminder note will be sent home approximately oneweekprior to the scheduled date ofthe clinic.
You will receive a record ofimmunization after the vaccine is given.
InManitoba, immunizations arevoluntary and aregiven withthe consent ofthe parent or legal guardian.
Please ensure the consent form is returned by February 10. 2016. to confirm that you have received
this information. Ifyou have any questions, please contact your Public Health Office at the number
listed on the top ofthis letter.
RIVER EASTANDTRANSCONA
845 RegentAvenueW
Winnipeg MB R2C 3A9
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Tel: 204.938.5555
Fax: 204. 938. 5296
Fevrier 2016
Lettre auxfamiliesdesQkvesde9 annieau sujet de1 administrationduvaccincontre la diphterie,la
coquduche acellulaire et Ie tetanos Tdap (DCaT) ft ces elives.
Leprogrammedesantepubliquede 1'OfBceregionaldela santedeWinnipeg(ORSW)of&eIevaccincontrela
diphterie, la coqueluche acellulaire et Ietetanos Sitous les eleves de
9 annee.
Onadmimstredesinjectionsderappelperiodiquesduvaccincontreladiphterie, la coquelucheet Ietetanosaux
enfants et auxadultes. Lademiere dose de rappel desjeunes en&iits duvaccin contre la diphterie, la coqueluche
et Ietetanosestadministreevers 4 a 6 anset contientegalementIevaccincentrelapoliomyelite. II sepeutque,
depuis,votre enfantaitresulevaccinTdap (DCaT)ouunvaccincontreIetetanoset la diphterie(TD) s'il a etc
traite pour une coupure sur la peau.
Nous verifierons Ie camet de vaccination de votre en&nt dans Ie registre provincial des immunisations, afin de
voir si c est 1c moment de lui admimstrer une injection de rappel de la diphterie, de la coqueluche ou du tetanos.
Si votre enfant a ete vaccine a 1 exterieur du Mamtoba, veuillezjoindre un exemplaire de son camet de
vaccinationauformulairedeconsentement,afinquenouspuissionsmettre nob'eregistreprovmcial a jour pour
votre enfaut.
Le personnel de sante publique vaccinera les eleves a 1 ecole a la date prevue au calendrier, en mars ou avril.
Apres avoir lu la feuille de renseignements ci-jointe sur Ie vaccin Tdap (DCaT), veuillez...
. remplir et signer Ie formulaire de consentement en cochant « Oui, je consens. »
ou « Non, je ne consens pas. »;
*
retourner ce formulaire i I fcole avant la date indiqute d-dessous.
Vous recevrez une note de rappel environ une semaine avant la dateprevue de vaccination.
Vous recevrez un certificat de vaccination une fois Ie vaccin administre.
Lavaccination est facultative au Manitoba et les vaccins ne sont admimstres qu'avec Ie consentement des
parents ou tuteurs legaux.
VeuiIIez vous assurer de retourner Ie formulaire de consentement avant Ie afin de confirmer que
vous avez bien reyu ces renseignements. Si vous avez des questions, veuillez vous adresser au bureau de
sante publique devotre localite aunumero qui figure au haut de la presente letter.
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FFICE USE ONLY
Winitipeghtjiioiul Officei^tonil dela
HealthAutixmty santidsWlmlptg
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BNKS>eck, D Initials.
Tetanus DiphtheriaAcellular Pertussus BoosterfTdap) Immunization Consent Form
Formulaire deconsentement pour I'injection de rappel du vaccin diphterie, la coqueluche acellulaire et
Ie Wanes (DcaT)
Surname / Worn defamille.
Given Name/PnSnom
Date of Birth (year/month/day)
Date de na/ssance (annSe/mois^our)^
Gender/Sexe dMale/Masc. DFemale/Fgm.
School I tale
Grade lAnnSe
PersonalHealthInfomnationNumber(PH\N'ilNum6rod'identiScaSonmSiScalpersonnel(NIMP)
ManitobaFamilyRegistration Number (MFRN)//Vum&odrmmato'cute(fonfemi7(a/d8San(6Man;to6a
Health History//lntecectentsmed;cau
Parent or Guardian to Complete I A re
1.Doesyourchildhaveanyallergies? IL'enfantsouffre-t-ild'allerg'es? D NoI Nond Yes/Ou/
Ifyes, please describe/S'ou/. prerisez.
2.uoesyourchildhaveanyheaIthconditionsthatre_quireregularwsitstoadoctor?/
l'obligeSvoirunm6dedndefasonp6riodique? D No/Won dYes/Ou/
tosnfan(9s(-i7aff8»nfd'unorot)»me (tosanMoui
Ifyes, please describe/S/ oui, p^c/sez.
3.Isyourchildtakinganymedications?/ Est-ce quevotre enfantprend desmSdicamentsPQNo/Won D Yes/Ou/
lfyes, pleasedescribe/S/ oui, pr6cisez.
4. Hasyourchildeverhadareactiontoavaccine?/l/ofreenfen(a-Md^suunef$acfcngrav8aui/acdndanstepsss^?
D No/Aton D Yes/Oui
Ifyes. pleasedescribe/S/ oui, precisez,
5. Isyourchildpregnant?/£s(-ce quevotieenfantestenceinte? D No/WonQ Yes/Ou
Consent / Consenteme;
Pleasereadtheattachedfactsheet. ; 1/eu///ez//re lafeullledemnseignements ci-jointe.
IconsenttotheaboyenamedpersonwahfingtheTdapvaceine/JeconsensafairBadmm/sfrsrt/apsraonnesusnommie
levaccinTdappcaT). dYes/Ou/ dNo/Aton
.
I have read and understood the factsheetregarding thevaccinethat I amconsenting to beadministered totheabove name
asindicated.'
<.J'ailuetjecomprends lafeuillederenseigrnemetfs surfevaccinquejeconsensa fareadministrerAlapersonnesusnommSe, telqifilestindique. »
Date
.
Signature.
Print Name/Wom en lettiemou es
O^arentorLegal Guardian only/ffare/rfoufufeurASfla/ssufeimenf)
.
ContactNumbers/Contoct;
Home/Oom. _
May2015/mai 2015
Work/Trai/._
_CeU
For staff use only:
The vaccine identified below was administered.
Data
Date Y(M/D
Product
Lot#
Route
Site
Dlntramuscular
DRightdeltoid
Dose
Nurees Signature
DLeftdeltoki
Dlntramuscular
DRightdeltoid
DLeftdeltoid
Date Y/M/D
May2015/maf20^
Progress Notes
Signature
entry