Meningococcal W
Vaccination Programme
Consent Form
ADDRESS
Street number Flat number Rural number
Street name
Suburb or rural locality
Town, city or district
Phone number
Daytime Evening Mobile
School
Family name (last name)
First name(s)
Also known as
NHI
Date of Birth
Day Month Year
Gender Male Female
Your Family Doctor’s name Phone
Medical Centre name
Address
With which ethnic group
does your child most closely
identify?
(You may tick more than one)
Please specify
Other
NZ European Maori Paci c Asian
If you want your child to receive the Meningococcal W (Menactra or Nimenrix A,C,W,Y)
vaccine please complete and sign the CONSENT (AGREE) section below.
Aged 16 years or over? You can complete this form yourself. Remember to talk to your mum,
dad, or caregiver before you decide.
YOUTH AGED 16 YEARS AND OVER – I AGREE to receiving the ONE Meningococcal W (Nimenrix) vaccine.
I understand my doctor will be informed that I have received the vaccination.
Print name Signature Date
Print name Signature Date
I have completed this form myself and confirm I am aged 16 years or older
I have read the information pamphlet on Meningococcal W vaccine (Menactra or Nimenrix)
I AGREE to this child receiving ONE Meningococcal W Vaccine (Menactra or Nimenrix).
I am the parent/guardian or have verbal consent from the parent or guardian.
If yes, please briefly explain
Yes
No
Does your child have any
health problems?
If yes, please briefly explain
Yes
No
Does your child have any
allergies?
If yes, please briefly explain
Yes
No
Has your child ever had a serious
problem after immunisation?
If yes, please briefly explain
Yes
No
Has your child received any
immunisations in the past month?
VACCINATOR TO COMPLETE:
Meningococcal W (Menactra or Nimenrix)
Vaccinator's name Signature
Adverse Reactions (describe)
Follow up information (if required)
Administration site Right deltoid
Left deltoid
Right vastus
lateralis
Left vastus
lateralis
Other AEFI or concern Severe AEFI with anaphylaxis
CARM notified ACC form completed
Time given
Day Month Year
Please circle vaccine given:
Date given
Batch number
Temperature
Expiry Date
Day Month Year
Own car Car pooled Walked
Kaiawhina Bus Friend’s car
Other: please specify
Facebook Newspaper Radio
Word of mouth GP TV
Northland DHB Website Ministry of Health
Other: please specify
Very good
Good
Acceptable
Poor
Very poor
Date
NHI
Name
1. Number of people in the following age groups living in the same household:
2. How did you get to the immunisation center today?
3. How did you come to know about the MenW Immunisation Programme?
4. Information provided in regard to the MenW Immunisation Programme was:
5. Do you have any further suggestions:
Thank you for your time
Age groups Number of people Age groups Number of people
9 months to <5 years 20 years to 59 years
5 years to < 13 years 60 years and over
13 years to < 20 years
Additional Information Sheet
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