DHE,C

ffiffiffi

Catherine E. Heiel, Director ?irt;tic1t;;y rtttr/ fttt;i1;;ji7g tl,t /'rrtlr/; $thr: publit',ti*1 tly r;.;t i;z;y::t:;ti

January 2016

Dear Parents/Guardians

:

The Tdap vaccine protects children from three serious diseases: tetanus, diphtheria, and pertussis (whooping cough). It is recommended that all children receive one (1) dose of Tdap vaccine at age ll or 12. Tdap is one of four vaccines recommended for children to receive at age lI or 12. The other three recommended vaccines are human papilloma virus (HPV) vaccine, meningococcal vaccine (MCV4) and a yearly flu vaccine. South Carolina state law requires that students must show proof of receiving one (1) dose of the Tdap vaccine at the start of their seventh-grade school year or they will be subject to suspension. The South Carolina Department of Health and Environmental Control (DIIEC) is working with your school district and the VaxCare Corporation to provide Tdap vaccine to current sixth graders at your child's school in the spring of 20L6. Our upcoming school clinic is a convenient way to get your child the Tdap vaccine and meet the seventh gade vaccinition requirements. To help make your child's Tdap vaccine as affordable as possible, if your child has: o Medicaid: your child's Medicaid will be billed. o No health insurance: you will receive a bill from DHEC for $13. o Private health insurance: your child's insurance company will be billed. If insurance does not cover the vaccine, you will receive a bill from VaxCare or DHEC, not to exceed $50 per dose.

If you would like your child to get a Tdap vaccine at school:

1.

2. 3.

Read the Vaccine Information Statement (VIS) to learn more about the Tdap vaccine. The VIS, the DHEC and VaxCare Privacy Notices, and more information about our school Tdap vaccine clinics can be found at www.scdhec.gov/Tdap. Your school's nurse can also provide you with the paper copies of these forms. Complete both sides of the Parent Consent Form. Please print and use black int<. your answers to the health questions on the form will help us decide if your child is able to get the Tdap shot at school.

Return the Consent Form to the school within live (5) days of receiving this letter. Please do not attacha check or cash to the consent form.

Once you have returned the Parent Consent Form, please contact the DHEC Regional Immunization Office for your county (refer to list on the back of this letter) before the scheduled vaccination clinic, if any of the following events occur: o There arc any significant changes in your child,s health. o You decide you no longer want your child to receive the Tdap vaccine at school.

If your child

has not yet received the Tdap vaccine, please take advantage of this opportunity. Talk to your child,s

health care provider or contact your local DHEC health department to obtain the other three recommended vaccines. Sincerely,

lt*o

A ?fr, fr\' tvt FH

Teresa Foo MD, MPH

Medical Consultant, Division of Immunization and prevention

DHEC Regional Immunization Office Contact Information:

.

For parents of children in participating schools in Allendale, Bamberg, Beaufort, Berkeley, Calhoun, Charleston, Colleton, Dorchester, Hampton, Jasper, and Orangeburg counties, please call (843) 953-0080.

.

For parents of children in participating schools in Aiken, Bamwell, Chester, Edgefield, Fairfield, Kershaw, Lancaster, Lexington, Newberry, Richland, Saluda, York counties, please call (803) 320-2467

.

For parents of children in participating schools in Abbeville, Anderson, Cherokee, Greenville, Qreenwood, Laurens, McCormick,. Ocoqeg,, Pickens, Spartanburg, Union counties, please call (864) 596-2227 Ext.246.

.

.

For parents of children in participating schools in Chesterfield, Clarendon, Darlington, Dillon, Florence, Georgetown, HorrSz,Lee, Marion, Marlboro, Sumter, Williamsburg counties, please call (843) 673-6570.

I

DISEASES and the VACCINES

THAI PREVENT THEN,l

I

INFORMATION FOR PARENTS

ffi

Vaccines for Preteens and Teens: What Parents Should Know -.ii J!C.t?. IJNE l,lj

Why does my child need vaccines now? Vaccines aren't just for babies. Some of the vaccines that babies get car wear offx kids get older. And as kids grow up they may come in contact with difi-erent diseases than when

they were babies. There are vaccines that can heip protect your preteen or teen from these other illnesses.

What vaccines does my child need? Tdap Vaccine This vaccine helps protect against three serious diseases: tetanus, diphtheria, and perhrssis (whooping cough). Preteens should get Tdap at age 11 or 12. Ifyour teen didn't get a Tdap shot as a preteen, ask the their doctor or nurse

healthy preteens and teens can get very sick from the flu and spread it to others. While all preteens and teens should get a fluvaccine,

itt

especially important for those

with

chronic health conditions such as asthma, diabetes, and heart disease to get vaccinated. The best time to get the flu vaccine is as soon after itt available in your communiry ideally by October. While itt best to be vaccinated before flu begins causing illness in your communiry flu vaccination can be beneficial as long as flu viruses are circulating, even in January or later.

When should my child be vaccinated?

about getting the shot now.

A good time to get these vaccines is during a yearly health checkup. Your preteen or teen can also get these vaccines at a physical exam required for sports, school, or camp. It's a

MeningococcalVaccine

good idea to ask the doctor or nurse every year if there are any vaccines that your child may need.

Meningococcal conjugate vaccine protects against some of the bacteria tiat can cause meningitis (swelling of the Iining around the brain and spinal cord) and septicemia (an infection in the blood). Preteens need the first meningococcal shot when they are 11 or 12 years old and a second meningococcal shot at age16. Teens who got the meningococcal shot when they were 13,14, or 15 years old should still get a second shot at age 16. Older teens who haven't gotten any meningococcal shots should get one dose as soon as possible.

HFUVaccine Human papillomavirus (HPV) vaccines help protect both girls and boys from HPV infection and cancer caused by HPV. Two HPV vaccines protect girls from the types of HpV that cause most cervical cancer. One HpV vaccine also helps protect both girls and boys from anal cancer and genital warts. HPV vaccines are given to preteens as 3 shots over 6 months when they are 77 or l2years old. preteens and teens who haven't started or finished the HpV vaccine series shouLd ask the doctor or nurse about getting them now.

Flu Vaccine The annual flu vaccine is the best way to reduce the chances of getting seasonal flu and spreading it to others. Even

What else should I know about these vaccines? These vaccines have all been studied very carefully and are safe. They can cause mild side effbcts, like soreness or redness in the parl of the arm where the shot was given. Some preteens and teens might faint after getting a shot. Sitting

or lying down when getting a shot and then for about 15

nfnutes after the shot, can help prevent fainting. Serious side effects are rare. It is very important to tell the doctor or nurse if your child has any serious allergies, including allergies to yeast, latex, or chicken eggs,beforethey receive any shots.

How can I get help paying for these vaccines? The Vaccines for Children (WC) program provides vaccines

for children ages 18 years andyounger, who are not insured, Medicaid-eli$ble, American Indian orAlaska Native. you can

find out more about the WC program by going online to www. cdc.gov and typing WC in the search box.

Where can I learn more? Talk to your child! doctor or nurse about what vaccines they may need. You can also find more information about these vaccines on CDC's Vaccines for Preteens and Teens website at www.cdc. govlvaccines /teens.

U.S. Department

of

Health and Human Services Centers for Disease a

Control and Prevention

Parent Consent for Tdap Vaccination

D-LE-C

ffiw= VoxCore STUDENT FIRST

FOR CLINIC UsE ONLY Partner lD:

Partner

flvrc f]vnx

Name:

ISC DHEC - Midlands flinir

lfl.

flstut"

Vaxcare has partnered with your healthcare provider to provide immunizations.

Region

llongleaf Middle

MI N

NAME

STUDENT LAST

School

f Rtirn !

Native

Black / Afr

AGE

NAME

Amer. l-l

l-l

Hawaiian / Pac

tllrrlll

GRADE

ll

GENDER,

TM

l--''--"trr

f wr'it" Iottrer

Hispanic

APT/SUIIE clTY rr

ADDRESS

4074309

,

[ , ] r r L , , , , , , ll--]l , , ' , , ' ' ' ' ' ' ' ' ' ll I

STREET

Consent lD:

I

School Name:

1659234

ETHNICITY I-lAmer. lndian /Alsk.

All bills for privately insured patients will comefrom eitherVaxGre or DHEC.

I

ITAIE _ZP

ll

PARENT/GUARDIAN HOME PHONE:

l|I

l,l

T

PARENT/GUARDIAN CELL PHONE:

fl

rnsunexcr

nRv

f ctcrun f] Gotden Rule f, [acas [Retna Care Carolina Blui choice fl coventry I Humana I fJ f

RELATIONSHIPTOTHE SUBSCRIBER/INSURED:

f]Spouse f

!sett

t*ait Handlers

f

Medcost

L_l

wted

Mutual

PAr

f

tl

Tricare

,f

urran

flwellpath

unned Healthcare

Dependent SUBSCRIBER/INSURED DOB (MM.DD.YYYY)

GENDER:

Itvt

Ir lhave no insurance or Medicaid coverage for mv child

Fm;

I

5( lmmunization Registry for public health purposes. I unconditionally and irrevocably waive any right to a trial by jury, to the maximum extent allowed by law, for any claim oraction againstVax(are arising out oforrelated tothis seruice, and that anysuch (laim or aGtion shall be determined solely on an individual basis through arbitration in accordance with (ommercia! Arbitration Rules of the American Arbitration Association. Neither I norVax(are shall be entitled to join or consolidate claims in arbitra' tion by or against other individuals or entities, or arbitrate any claims as a representative member of a class or in a private attorney genelal capacity. The foregoing arbitration provisions do not affect or apply to any disputes with or claims by or against DHE( or any action to which DHEC is a party, regardless of whether Vax(are i5 individual indicated above, to consent to this vaccine administration. SIGNATURE

of PARENT

a

oT LEGAL GUARDIAN

DATE

/

flvrc

LOT

!sr []esx

Ivaxcene f,srere

to student

[Jnable to vaccinate student due to gilento shdent

[Lo [no Eot",-

L-l'un"tl"tot,u".i*tdfom

PATI ENT/STUDENT'S ASSIGNED CLASSRM TEACH ER SIGNATURE

NURSE SIGNATURE I

NUE I h€reby atten by sig@ture abore that the patient {or guardian of patient} in question has given th€Tdap Vaccire lnfomtion Shets and has giwn witten conent for vaccination.

DHECTdapCF.0l 081 6 All rights DHEC 0780 (01 /201 6)

I-l "whrt to Kno* After..."given

t

ben

reserved - VaxCare Corp. Printed in

I

Teacher:

the

usA

(888) 829-8ss0

www.vaxcare,com

I

hereby

attst

by signature abwe that the identity ofthe

patist

in question has

Turn Page

ben rerified

Over

r)

Tdap Vaccination: vaccination. lf

1.

a

your child a Tdap The following questions will help us determine if there is any reason we should not give

question

is

not cleat please ask your healthcare provider to explain it.

NO

YES

Has your child previously received a dose of Tdap vaccine (anytime on or after.his/her 7th

tr

tr

birthday)?

lf you answered NO to Question #1 above, ptease complete Questions *2 - #7 if you want your child to receiveTdap vaccine.

2.

Has your child ever had a serious allergic reaction after a dose of any tetanus, diphtheria, or pertussis containing vaccine (DTB DTaP, DT,Td, orTdap) that caused any of the following:

YES

NO

YES

NO

a

YES

tr

NO

T

following

YES

u

NO

u

YES

NO

wheezing, trouble breathing, hives aqd itching all over the body, swelling-in the mouth or throat, very low blood pressure or shock?

3.

to latex that caused any of the following: wheezing, trouble breathing, hives and itching all over the body, swelling in the mouth or throat, very low blood pressure or shock?

4.

Has your child ever been in a coma or had long or multiple seizures

Has your child ever had a serious allergic reaction

within 7 days of getting

Has your child had severe swelling or severe pain after a previous dose of any of the vaccines: DTB DTaB DI,Td, orTdaP?

6.

Has

7.

Does your child have epilepsy or another nervous system problem?

tr

tr

dose of DTP or DTaP vaccine?

5.

tr

tr

-

your child ever had Guillain Barre Syndrome (GBS) (a rare type of temporary severe muscle weakness and paralysis)?

tr

tr

YES

NO

tr

T

lf you answered YES to any of the questions above. your child cannot receive the Tdap vaccine at the school's vaccination clinic. Please contact your primary healthcare provider about the Tdap vaccine.

Notes:

FOR CLINIC USE ONLY

EVoxCore DHECTdapCF.010816All rightsreserved-Vaxcarecorp.PrintedintheusA DHEC 0780 (01/2016)

L_.1

(888)829-8550 www.vaxcare.com

vFc

L_l vAX

l_l

state