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Human Papillomavirus _HPV_ Vaccine

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					                               Human papillomavirus (HPV) Vaccine
                            Vaccination Consent Form

The HPV vaccine helps protect against cervical cancer and is being offered at school (or
college). The leaflet that accompanies this form tells you more about the vaccine. The impact of
the vaccine will be evaluated through the cervical cancer screening programme using
computerised immunisation records. Your GP practice will also be advised about vaccinations
so that they can update the records. Parents must act in their children’s best interests in
considering consent and need to recognise that children age 16 years and older, and younger
ones who fully understand the issues, are legally able to make their own decision about consent.
Please complete this form and return it to the school before the vaccination is due to be given. If
you have more questions, please contact the school nurse or other health professional or go to
www.immunisation.nhs.uk/hpv for further information.

Girl’s full name (first name and surname):
Date of Birth:
Home address:


Daytime contact telephone number for parent/carer:
School:


GP name and address:


Year group/class:


Consent for all three HPV vaccinations (Please complete one box only)
Yes, I want my daughter to/I want to*(delete as appropriate) receive the full course of the three HPV
vaccinations
Parent/Guardian / Person being immunised*(delete as appropriate) Name:
Signature:
I am the Parent/Guardian/Person being immunised* (delete as appropriate)
Date:
* delete the answer that does not apply
No, I do not want my daughter to / I do not want to * have the HPV vaccine
Parent/Guardian / Person being immunised* (delete as appropriate) Name:
Signature:
I am the Parent/Guardian / Person being immunised* (delete as appropriate)
Date:                         Human papillomavirus (HPV) Vaccine
                             Vaccination Consent Form

If, after discussion, you decide you do not want the vaccine or if you as the parent decide you do
not want your daughter to have the vaccine, it would be helpful if you would give the reasons for
this on the form and return it to the school.




Any side effects following the vaccination should be reported to the school nurse
                                  or GP practice


Thank you for completing this form. Please return it to the school or college as soon as possible


                                       FOR OFFICIAL USE ONLY

                                                                                          Where
                         Site of                                 Immuniser
                                        Batch number/                                  administered
                        injection                                (name and
                                         expiry date                                 (school, college,
                     (please circle)                             signature)
                                                                                         GP etc)
1st vaccine          L arm    R arm
2nd vaccine          L arm    R arm
3rd vaccine          L arm    R arm
                               Brechlyn Feirws Papiloma Dynol (HPV)
                              Ffurflen Caniatâd Brechu

Mae’r brechlyn HPV yn helpu i ddiogelu pobl rhag canser ceg y groth ac mae’r ysgol (neu’r
coleg) yn ei gynnig. Mae’r daflen sy’n dod gyda’r ffurflen hon yn rhoi gwybodaeth ichi am y
brechlyn. Caiff effaith y brechlyn ei gwerthuso drwy raglen sgrinio canser ceg y groth gan
ddefnyddio cofnodion imiwneiddio cyfrifiadurol. Caiff eich meddyg teulu wybod am bob brechiad
iddo allu diweddaru ei gofnodion. Rhaid i rieni weithredu er lles eu plant wrth ystyried rhoi
caniatâd ac mae’n bwysig eu bod yn cofio bod gan blant 16 oed a throsodd, a phlant iau sy’n
deall y mater yn llawn, yr hawl cyfreithiol i roi’r caniatâd drostynt eu hunain. Llenwch y ffurflen a’i
dychwelyd i’r ysgol cyn dyddiad rhoi’r brechiad. Os oes gennych gwestiynau eraill, cysylltwch â
nyrs yr ysgol neu weithiwr iechyd proffesiynol arall neu ewch i www.immunisation.nhs.uk/hpv i
gael mwy o wybodaeth.

Enw llawn y ferch (enw cyntaf a chyfenw):
Dyddiad geni:
Cyfeiriad cartref:


Rhif ffôn y rhiant/gofalwr yn ystod y dydd:
Ysgol:


Enw a chyfeiriad y meddyg teulu:


Grŵp blwyddyn/dosbarth:


Caniatâd i roi’r tri brechiad HPV (Llenwch un blwch yn unig)
Ydw, Rwyf am i fy merch/Rwyf am*(dileer yn ôl y gofyn) gael y cwrs llawn o dri brechiad HPV

Rhiant/Gwarcheidwad/Y person sy’n cael ei imiwneiddio*(dileer yn ôl y gofyn) Enw:
Llofnod:
Y fi yw’r Rhiant/Gwarcheidwad/Y person sy’n cael ei imiwneiddio*(dileer yn ôl y gofyn)
Dyddiad:
* dilewch yr ateb anghywir
Nac ydw, dw i ddim am i fy merch / dw i ddim am * gael brechiad HPV
Rhiant/Gwarcheidwad/Y person sy’n cael ei imiwneiddio*(dileer yn ôl y gofyn) Enw:

Llofnod:
Y fi yw’r Rhiant/Gwarcheidwad/Y person sy’n cael ei imiwneiddio*(dileer yn ôl y gofyn)
Dyddiad:
                               Brechlyn Feirws Papiloma Dynol (HPV)
                             Ffurflen Caniatâd Brechu

Os byddwch chi, ar ôl trafod, yn penderfynu nad ydych am gael eich brechu neu os byddwch chi,
fel y rhiant, yn penderfynu nad ydych am i’ch merch gael ei brechu, byddai’n ddefnyddiol pe
baech yn esbonio pam ar y ffurflen a’i dychwelyd i’r ysgol.




 Rhowch wybod i nyrs yr ysgol neu’ch meddyg teulu am unrhyw sgil-effeithiau ar
                               ôl cael brechiad


Diolch am lenwi’r ffurflen hon. Anfonwch hi yn ôl i’r ysgol neu’r coleg cyn gynted ag y medrwch.


                                AT DDEFNYDD SWYDDOGOL YN UNIG

                                                                                     Ble cafodd ei roi
                      Lleoliad y pigiad         Rhif y swp /
                                                                  Imiwneiddydd        (ysgol, coleg,
                       (rhowch gylch)          dyddiad terfyn
                                                                                     meddygfa ac ati)

Brechiad 1af      Braich chw     Braich dde
2il frechiad      Braich chw     Braich dde
3ydd brechiad     Braich chw     Braich dde

				
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