DECLARATION OF CONSENT to the VACCINATION AGAINST MEASLES, MUMPS and RUBELLA mit M-M-RvaxPro

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1 ENGLISCH VIENNA CITY ADMINISTRATION MAGISTRAT DER STADT WIEN Municipal Department 15 Public Health Services of the City of Vienna Magistratsabteilung 15 Gesundheitsdienst der Stadt Wien DECLARATION OF CONSENT to the VACCINATION AGAINST MEASLES, MUMPS and RUBELLA mit M-M-RvaxPro EINVERSTÄNDNISERKLÄRUNG zur SCHUTZIMPFUNG GEGEN MASERN MUMPS und RÖTELN mit M-M-RvaxPro PLEASE ANSWER THE FOLLOWING QUESTIONS: BITTE BEANTWORTEN SIE DIE NACHSTEHENDEN FRAGEN: ( Please tick as applicable) ( Zutreffendes bitte ankreuzen) Has your child ever experienced complaints or adverse effects following a yes / ja no / nein vaccination? Hatte Ihr Kind bereits einmal nach einer Impfung Beschwerden oder Nebenwirkungen? Does your child currently have a high temperature or has your child had a yes / ja no / nein high temperature within the past two weeks? Does your child currently suffer from a cough, runny nose or sore throat? Does your child currently suffer from any other form of infection? Hat Ihr Kind derzeit oder in den letzten 2 Wochen Fieber? Leidet Ihr Kind derzeit an Husten, Schnupfen, Halsschmerzen? Besteht derzeit eine andere Infektion? Does your child suffer from any allergies? If yes, which allergy? yes / ja no / nein Leidet Ihr Kind an einer Allergie? Wenn ja, an welcher?... If your child is currently receiving an injection therapy to treat allergies: When did she or he receive the last injection? When will she or he receive the next injection? Falls Ihr Kind derzeit eine Injektionstherapie gegen Allergie-auslösende Stoffe erhält: wann war die letzte Verabreichung?... wann ist die nächste Verabreichung geplant?... Does your child suffer from congenital or acquired immune deficiency / yes / ja no / nein immune system disorder? If yes, which one? Liegt bei Ihrem Kind eine angeborene oder erworbene Immunabwehrschwäche/Immunerkrankung vor? Wenn ja, welche?... Does your child take medication such as cortisone, cytostatics and blood yes / ja no / nein thinning medication on a regular basis? If yes, which medication? Nimmt Ihr Kind regelmäßig Medikamente ein (z.b. Cortison, Zytostatika, zur Blutverdünnung)? Wenn ja, welche? Is your child currently undergoing chemotherapy and/or radiotherapy? yes / ja no / nein Bekommt Ihr Kind derzeit eine Chemo- und/oder Bestrahlungstherapie? MA 15 SD Seite 1/3 Einverständniserklärung zur Schutzimpfung Hepatitis B DVR:

2 ENGLISCH Does your child suffer from a severe or chronic illness? yes / ja no / nein If yes, which one? Leidet Ihr Kind an einer schweren oder chronischen Erkrankung? Wenn ja, an welcher?... Has your child recently undergone an invasive therapy (e.g. surgery)? yes / ja no / nein Musste Ihr Kind sich vor kurzem einer eingreifenden Behandlung (z.b. einer Operation) unterziehen? Does your child suffer from a chronic inflammatory disease of the brain or yes / ja no / nein spinal cord? Has your child ever had an epileptic fit? Leidet Ihr Kind an einer chronisch entzündlichen Erkrankung des Gehirns oder Rückenmarks? Hatte Ihr Kind je epileptische Anfälle? Did your child get any other type of vaccination in the past four (4) weeks? yes / ja no / nein If yes, which and when? Hat Ihr Kind in den letzten 4 Wochen eine andere Impfung erhalten? Wenn ja welche und wann?... Did your child receive blood, blood products or immunoglobulin in the yes / ja no / nein past three (3) months? Hat Ihr Kind in den letzten 3 Monaten Blut, Blutprodukte oder Immunglobuline erhalten? Please turn the page Thank you / Bitte wenden Danke MA 15 SD Seite 2/3 Einverständniserklärung zur Schutzimpfung Hepatitis B DVR:

3 ENGLISCH Please write in CAPITAL letters. Thank you / Bitte in Blockbuchstaben ausfüllen Danke Surname of the child / Familienname des Kindes Name of the child / Vorname des Kindes Address / Adresse Date of birth of the child: day/month/year Geburtsdatum des Kindes: Tag/Monat/Jahr Name of parent or legal guardian / Name der oder des Erziehungsberechtigten I confirm with my signature that I have carefully read and understood the information sheet and the package leaflet for the abovementioned vaccine (M-M-RvaxPro ). I have been informed about the composition of the vaccine as well as any contraindications for its administration and any potential side effects of the vaccination and have understood this information. Mit meiner Unterschrift bestätige ich, dass ich das Informationsblatt und die Gebrauchsinformation zum obengenannten Impfstoff (M-M-RvaxPro ) sorgfältig gelesen und verstanden habe. Ich wurde dort über die Zusammensetzung des Impfstoffes, sowie Gegenanzeigen zur Verabreichung und mögliche Nebenwirkungen der Impfung aufgeklärt und habe diese Informationen verstanden. I have been given the opportunity to discuss any questions with the school physician during the opening hours. I have been informed about the benefits and risks of the vaccination and do not need a personal discussion with the physician. Ich hatte Gelegenheit während der Dienststunden des Schulärztlichen Dienstes offene Fragen mit der Ärztin/dem Arzt zu besprechen, bin aber über Nutzen und Risiko der Impfung ausreichend aufgeklärt und benötige daher kein persönliches Gespräch. I hereby consent to the vaccination. / Ich bin mit der Durchführung der Schutzimpfung einverstanden Date / Datum Signature of parent / legal guardian / Unterschrift der oder des Erziehungsberechtigten PLEASE NOTE / HINWEIS: If you wish to talk to the school physician in person during the opening hours please sign this form only after the meeting and hand it to the physician. Wenn Sie die Möglichkeit eines persönlichen Gespräches mit der Ärztin/dem Arzt während der Dienststunden des Schulärztlichen Dienstes in Anspruch nehmen möchten, ersuchen wir Sie, diese Einverständniserklärung erst nach dem erfolgten Aufklärungsgespräch zu unterfertigen und der Schulärztin bzw. dem Schularzt persönlich auszuhändigen. Remarks by physician / Ärztliche Anmerkungen: Date / Datum Stamp and signature of physician / Stempel und Unterschrift des Arztes/der Ärztin MA 15 SD Seite 3/3 Einverständniserklärung zur Schutzimpfung Hepatitis B DVR:

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5 ENGLISCH VIENNA CITY ADMINISTRATION MAGISTRAT DER STADT WIEN Municipal Department 15 Public Health Services of the City of Vienna Magistratsabteilung 15 Gesundheitsdienst der Stadt Wien INFORMATION ABOUT THE VACCINATION AGAINST MEASLES, MUMPS and RUBELLA with M-M-RvaxPro In its vaccination recommendations, the Austrian Health Council has once more emphasised the importance of providing protection against measles, mumps and rubella for all children. Protection against infection is attained by two vaccination shots against measles, mumps and rubella. The first shot is given when the child is more than 12 months old. The second shot should be given before the child is 2 years old but at least 4 weeks after the first shot. All children should have received the second vaccination shot against measles, mumps and rubella by age 13 at the latest. For this reason, schools offer free-of-charge combined vaccination against measles, mumps and rubella for all children who attend the 1 st and 7 th forms and have not yet been vaccinated twice against measles, mumps and rubella. Even if your child has already contracted one or two of these diseases in the past, the measles-mumps-rubella vaccination is recommended and not harmful. It will only be possible to eradicate these diseases in the future if more than 90% of all children have been vaccinated. Measles is a highly contagious viral disease that occurs practically everywhere across the world and is accompanied by fever, coughing, conjunctivitis and skin rash. Persons infected with measles as well as persons with acute measles excrete the virus when speaking, coughing, sneezing, etc. ( droplet infection ). Since measles is highly infectious, the disease can quickly spread within a non-vaccinated group (e.g. a class of schoolchildren). Complications may include bacterial infections such as middle ear inflammation, bronchitis or pneumonia. Meningitis that may entail permanent damage can occur in rare cases. Very rarely, a disease of the central nervous system with particularly virulent and fatal progression may occur years after the infection. In its turn, rubella is a highly contagious, febrile infectious disease accompanied by skin rash and swelling of the lymph nodes. It is triggered by the rubella virus and occurs widely throughout the world. The disease is transmitted via droplet infection. Rubella infections are hazardous for women in the first three months of pregnancy, as they may cause grave damage to the embryo with congenital deformations of the brain, eyes and heart. Vaccination can minimise this risk. However, vaccination is not possible during pregnancy; by the same token, pregnancy should not occur in the first three months after vaccination. It is therefore urgently recommended to have girls vaccinated before puberty and in any case before the 13 th birthday at the latest. Mumps is a highly contagious viral disease transmitted via droplet infection. It is characterised by painful swelling of the salivary glands, in particular of the parotid gland. In a few cases, other glands of the body are involved as well, such as the testicles, ovaries and pancreas. If mumps is contracted after puberty, a painful inflammation of the testicles occurs in roughly one out of three male adolescents or adults; in rare cases, this may lead to sterility. Approx. 10% of the persons who have contracted the disease develop meningitis. The vaccine is a live vaccine with attenuated viruses. However, vaccinated persons are not contagious and pose no hazard for pregnant women. The combination vaccine provides protection against several diseases with just one injection. The currently used combination vaccine against measles-mumps-rubella is M-M-RvaxPro. MA 15 SD /2 Information zur Schutzimpfung MMR M-M-RvaxPro

6 ENGLISCH Please turn the page Thank you. Side effects Vaccinations may have side effects. The package leaflet, which is enclosed to this information sheet, provides more information about the composition of the vaccine as well as any contraindications for its administration and any potential side effects of the vaccination. Please inform your physician immediately of all reactions and side effects, in particular side effects that are not listed in this package leaflet. MA 15 SD /2 Information zur Schutzimpfung MMR M-M-RvaxPro

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