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HPV Vaccination Permission-Form 2025 Updated 3AUGUST

The document is a permission form for the HPV vaccine administered by the Ministry of Health and Social Services in Namibia. It provides essential information about the HPV vaccine, its purpose, administration details, potential side effects, and the voluntary nature of vaccination. Parents or guardians must sign to give permission for their child, aged 9-14, to receive the vaccine, with specific instructions for follow-up doses if necessary.

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174 views1 page

HPV Vaccination Permission-Form 2025 Updated 3AUGUST

The document is a permission form for the HPV vaccine administered by the Ministry of Health and Social Services in Namibia. It provides essential information about the HPV vaccine, its purpose, administration details, potential side effects, and the voluntary nature of vaccination. Parents or guardians must sign to give permission for their child, aged 9-14, to receive the vaccine, with specific instructions for follow-up doses if necessary.

Uploaded by

mukolofurinna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MINISTRY OF HEALTH AND SOCIAL SERVICES

NAMIBIA HPV VACCINE PERMISSION FORM

Name of Health Facility Vaccination site is attached to: Name of site Vaccination is administered:

District: Region: □ Outreach / Fixed


Child’s First & Last name:
Sex : ☐ Female DOB: ___ /___ /_____
Child’s Physical Address: Age: Nationality:

Parent’s Contact details: Guardian’s Contact details:

Important Information to the Parent/Guardian:

1. Human Papilloma Virus (HPV) Vaccine is the vaccine that protects you against the HPV.
2. HPV is a common Virus that is sexually transmitted and it can affect the skin, genital area and throat. It is
most known to cause Cervical Cancer.
3. HPV vaccine protects you from HPV before exposure but it does not treat existing infection.
4. The HPV Vaccine will be given to girls between the age of 9-14 years before they become sexually active.
5. One dose protects you for life. For the Immuno-compromised (with underlying illnesses/conditions) girls
require 2 doses, the second dose will be administered 6 months after the 1 st dose.
6. The HPV Vaccine like any other Vaccine may cause common minor side effects such as pain, redness or
swelling on the injection site, fever, headache or nausea.
7. All vaccinated children should be observed for at least 15 minutes for potential reactions. Should potential
reactions occur thereafter, children are advised to consult their nearest healthcare provider.
8. A qualified Health Worker will administer the vaccine and be available for enquiry.
WAIVER
1. I acknowledge the above information, and understand that the vaccine is voluntary.
2. I hereby give permission for my child to be vaccinated.
3. I undertake to ensure that my child receives the second dose if so required.

Parent/Guardian (Signature): ____________________________________Print Full Name:

_____________________________________

Signature of Child: ______________________________________________

Signed at _____________________________ on Date: ____/ _________/ _________

Area Below to be Completed by Vaccinator:


Vaccine
Administration Batch No. Manu/Lot No. Expiry Date: VVM Stage:
Name
□ Second
Gardasil 4 □ First Dose
Dose

Administration Site: □ Right Deltoid


Dosage: □ 0.5 ml

□ The Child was provided with information on HPV Vaccine by a Trained Health Care Worker and Permission to vaccinate was granted.

Vaccinator Name and Rank: _____________________________________________________________________________

Vaccinator Signature: _____________________________________________________________________________________

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