GSTT Immunisation Team – Covid 19 vaccination (Bexley)

COVID-19 vaccination provided by Guy's and St Thomas' NHS Foundation Trust

For any queries, issues or help completing this form please contact us on Covid19Schoolsvaccinationprogramme@gstt.nhs.uk
YOUNG PERSON'S VACCINATION CONSENT FORM FOR COVID-19 VACCINATION
Please note: the deadline for processing consent forms is at 9am one day prior to the School Vaccination Date unless your child’s school specifies a different date/time.

Please have your child’s nhs number with you when completing this form, to find their nhs number please use this link: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/
YOUNG PERSON'S DETAILS:*

First NameLast Name
Address*

Address Line 1

Address Line 2

CityState / Province

Post Code
Date Of Birth*

DayMonthYear
Date
Gender

MaleFemalePrefer not to say
Child's Ethnicity
School*
Class/Form
Doctor’s name/ Surgery
NHS number (if known)
If you do not know the child's nhs number please use this link: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/
Parent's Mobile Number*
Please enter a valid mobile number.
Parent's Email Address

Confirmation Emailexample@example.com

Has your child tested positive for COVID-19 during the last 12 weeks?*

YesNo
Please let us know the date of the positive PCR test

DayMonthYear
Date
Are you booking a first, second or Booster dose for your child?*

First dose of a Covid-19 vaccinationSecond dose of a Covid-19 vaccinationBooster Dose (Over 16s who had their 2nd dose more than 3 months ago)
When did your child have a first dose COVID-19 vaccination?

DayMonthYear
Date
When did your child have a second dose COVID-19 vaccination?

DayMonthYear
Date

Parental/ Guardian Consent

I confirm that I have parental responsibility for this child.
We accept consent from one person with parental responsibility. If there is a reason why we should not accept consent from one parent i.e. a court order is in place, please give details below.
Please select...*

I CONSENT for my Child to have the COVID-19 vaccinationI DO NOT CONSENT for my Child to have the COVID-19 vaccination
Please let us know why
Name*

First NameLast Name
Relationship to child*
Please specify
Date

DayMonthYear
Date

Protecting your data
Data Sharing (GDPR)

As part of the vaccine roll out, the Trust will process the data you have provided above within a secure and limited access environment. A record of the vaccine will be made on the National Immunisation Vaccination service (NIVS) system.

Anonymised data will be shared with NHS England via the National Immunisation Vaccination service (NIVS) as part of the Covid vaccine management.

Your child’s GP will receive an update of the vaccination information via NIVS.

The trust processes your data as part of its public task, provision of health services and public health duty under GDPR . The Trust has also been mandated by the UK government to share this data as part of the Covid 19 response under the Control of Patient Information notice.

Please see below links for further information:

https://www.gov.uk/government/publications/coronavirus-covid-19-notification-of-data-controllers-to-share-information/coronavirus-covid-19-notice-under-regulation-34-of-the-health-service-control-of-patient-information-regulations-2002-general

Use of Jotform: https://www.hrch.nhs.uk/download_file/view/842/377 -

The NIMS/NIVS privacy notice is available at: https://www.england.nhs.uk/contactus/privacy-notice/national-flu-vaccination-programme/

Public Health England privacy notice: https://www.gov.uk/government/publications/phe-privacy-information/covid-19-privacy-information

HRCH privacy notice: Your patient records : Hounslow & Richmond Community Healthcare (hrch.nhs.uk)

GSTT Privacy notice : https://www.guysandstthomas.nhs.uk/patients-and-visitors/patients/your-care/privacy-notice-COVID-19-vaccinations-for-individuals.aspx
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COVID-19 vaccination provided by Guy's and St Thomas' NHS Foundation Trust

YOUNG PERSON'S VACCINATION CONSENT FORM FOR COVID-19 VACCINATION

Parental/ Guardian Consent

SECTION 3:

Protecting your data