Diphtheria, Tetanus & Polio
Immunisation

This immunisation will protect your child against 3 diseases – Tetanus, Diphtheria and Polio. They need a total of 5 doses to give themoptimum immunity – 1st, 2nd 3rd as a baby, 4th before starting school (PSB) and the 5th is due now. Please read the enclosed booklet and complete the consent form and return it to school before the vaccination is due. Information about the vaccination will be put on your child’s school health and GP records.

PLEASE NOTE: This vaccination is not routinely offered by GP’s, it will be given in school by the school nurse team.

If the consent form is not returned we will ask your child if he/she wishes to consent on the day and will ask for them to complete the consent form, providing they understand all the facts that are given to them.

Childs Name:
(first name and surname) / Date of Birth:
NHS Number
Home Address: / Daytime telephone contact number of parent/carer:
School: / Class:
GP Name and Address: / Male/Female

Did your child receive a: Please circle

Course of 3 baby injections / YES / NO
Pre School Booster (PSB) / YES / NO
Date of more recent Tetanus, Diphtheria & Polio Booster if given (ie A&E attendance or travel vaccine (which included the DTP) in the last 10 years. / YES / NO
(if yes DD/MM/YY)
Has your child had a bad reaction to a previous injection? If yes, give details: / YES / NO
Does your child have any medical conditions? If yes, give details: / YES / NO
Is your child taking any medicine or tablets?
If yes, give details: / YES / NO
Is your child allergic to neomycin, streptomycin or polymixin B? / YES / NO / UNKNOWN

Any side effects following the DTP immunisation should be reported to

the School Nurse or your GP

I have read and understood the booklet on secondary school immunisations

I WANT my Son/Daughter to receive the DTP Immunisation / I DO NOT WANT my Son/Daughter to receive the DTP Immunisation
Signature
(Parent/Guardian) / Signature
(Parent/Guardian)
Date: / Date:

* For office use only. Community immunisation policy followed Yes

Date & time of Immunisation / Site of Injection (please circle) / Make & Batch number/expiry date / Immuniser (please print) / Where administered (school)
L arm R arm

Please make sure you check with your GP/RED BOOK where you are in the schedule and arrange any further immunisations with your GP if required.