School Immunization Consent Form ‫ﻧﻤﻮذج اﻟﻤﻮاﻓﻘﺔ ﻋﻠﻰ إﻋﻄﺎء اﻟﻠﻘﺎﺣﺎت اﻟﻤﺪرﺳﻴﺔ‬

Student’s Full Name: -------------------------------------------------- ------------------------------------------- :‫اﻟﻄﺎﻟﺒﺔ‬/‫اﻻﺳﻢ )اﻟﻜﺎﻣﻞ( ﻟﻠﻄﺎﻟﺐ‬

School: --------------------------------------------- Grade:------------
DOB:---------------------------------Sex: □ Male
Nationality: -----------------------------------------------------------
The School Nurse/ Doctor or School Health Section team, DHA will provide
the student with the following Vaccines at schools as booster doses for the
pre–school vaccination national program as recommended by DHA
--------------- :‫ اﻟﺼﻒ‬--------------------------------------------‫اﻟﻤﺪرﺳﺔ‬
□ Female ‫□ أﻧﺜﻰ‬ ‫ □ ذﻛﺮ‬: ‫اﻟﺠﻨﺲ‬ ------------------ :‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬
-------------------------------------------------------------------------- :‫اﻟﺠﻨﺴﻴﺔ‬ 
‫ دﻛﺘﻮر اﻟﻤﺪرﺳﺔ أو ﻓﺮﻳﻖ ﻗﺴﻢ اﻟﺼﺤﺔ اﻟﻤﺪرﺳﻴﺔ ﻣﻦ ﻫﻴﺌﺔ اﻟﺼﺤﺔ دﺑﻲ‬/‫ﺳﻮف ﻳﻘﻮم ﻣﻤﺮض‬
‫ وﺗﻌ ّﺪ ﻫﺬه اﻟﻠﻘﺎﺣﺎت ﺟﺮﻋﺎت ﻣﻨﺸﻄﺔ‬.‫ﺑﺈﻋﻄﺎء اﻟﻠﻘﺎﺣﺎت اﻟﺘﺎﻟﻴﺔ ﻓﻲ اﻟﻤﺪرﺳﺔ وﻓﻘﺎ ً ﻟﻠﺠﺪول اﻟﺘﺎﻟﻲ‬
.‫ﻣﻜﻤﻠﺔ ﻟﻠﺒﺮﻧﺎﻣﺞ اﻟﻮﻃﻨﻲ ﻟﻠﺘﺤﺼﻴﻦ ﺣﺴﺐ اﻟﺘﻮﺻﻴﺎت اﻟﻤﻌﻤﻮل ﺑﻬﺎ ﻣﻦ ﻗﺒﻞ ﻫﻴﺌﺔ اﻟﺼﺤﺔ ﻓﻲ دﺑﻲ‬

‫اﻟﺼﻒ‬ ‫ﻃﺮﻳﻘﺔ إﻋﻄﺎء اﻟﻠﻘﺎح‬ ‫اﻟﻠﻘﺎح‬ ‫ﻣﺴﺘﺤﻖ‬ ‫ﻣﺘﺄﺧﺮ‬

Grade Administration route Vaccine Due Overdue
‫ﺣﻘﻨﺔ ﺗﺤﺖ اﻟﺠﻠﺪ‬ ‫ اﻟﻨﻜﺎف‬،‫ اﻟﺤﺼﺒﺔ اﻷﻟﻤﺎﻧﻴﺔ‬،‫اﻟﺤﺼﺒﺔ‬
 -------------
Subcutaneous injection Measles, Mumps, Rubella (MMR)
(‫اﻟﺮﺑﺎﻋﻲ )اﻟﺪﻓﺘﻴﺮﻳﺎ واﻟﻜﺰاز واﻟﺴﻌﺎل اﻟﺪﻳﻜﻲ اﻟﻼﺧﻠﻮي وﺷﻠﻞ اﻷﻃﻔﺎل اﻟﻌﻀﻠﻲ‬
Dtap-IPV Vaccine: ( Diphtheria, Tetanus, acellular pertussis and injectable polio) 
‫ﺣﻘﻨﺔ ﺑﺎﻟﻌﻀﻞ‬
OR  --------------
‫اﻟﺼﻒ اﻷول‬ Intramuscular Injection
Grade 1 (‫اﻟﺜﻼﺛﻲ )اﻟﻜﺰاز واﻟﺪﻓﺘﻴﺮﻳﺎ واﻟﺴﻌﺎل اﻟﺪﻳﻜﻲ اﻟﻼﺧﻠﻮي‬ 
Tdap vaccine: (Tetanus, diphtheria, acellular pertussis)
‫ﻧﻘﻄﺘﻴﻦ ﺑﺎﻟﻔﻢ‬ ‫ﺷﻠﻞ اﻷﻃﻔﺎل اﻟﻔﻤﻮي‬
 ---------------
Two Oral Drops OPV Vaccine (Oral Polio Vaccine)
‫ﺣﻘﻨﺔ ﺗﺤﺖ اﻟﺠﻠﺪ‬ ‫اﻟﺠﺪﻳﺮي اﻟﻤﺎﺋﻲ‬
 ---------------
Subcutaneous injection Varicella vaccine
‫اﻟﺼﻒ اﻟﺜﺎﻣﻦ‬ ‫ﺣﻘﻨﺔ ﺑﺎﻟﻌﻀﻞ‬ ‫اﻟﺘﻴﺘﺎﻧﻮس واﻟﺪﻓﺘﻴﺮﻳﺎ واﻟﺴﻌﺎل اﻟﺪﻳﻜﻲ اﻟﻼﺧﻠﻮي‬
 ---------------
Grade 8 Intramuscular Injection Tdap vaccine :(Tetanus, Diphtheria, acellular Pertussis )
‫ﺣﻘﻨﺔ ﺑﺎﻟﻌﻀﻞ‬ 1 ‫ﻟﻘﺎح اﻟﻮﻗﺎﻳﺔ ﻣﻦ ﺳﺮﻃﺎن ﻋﻨﻖ اﻟﺮﺣﻢ ﺟﺮﻋﺔ‬
 ---------------
Intramuscular Injection HPV Vaccine 1st dose
‫اﻟﺼﻒ اﻟﺜﺎﻣﻦ‬ ‫ﺣﻘﻨﺔ ﺑﺎﻟﻌﻀﻞ‬ 2 ‫ﻟﻘﺎح اﻟﻮﻗﺎﻳﺔ ﻣﻦ ﺳﺮﻃﺎن ﻋﻨﻖ اﻟﺮﺣﻢ ﺟﺮﻋﺔ‬
 ---------------
(‫)إﻧﺎث‬ Intramuscular Injection HPV Vaccine 2nd dose
Grade 8 ‫ﺣﻘﻨﺔ ﺑﺎﻟﻌﻀﻞ‬ 3 ‫* ﻟﻘﺎح اﻟﻮﻗﺎﻳﺔ ﻣﻦ ﺳﺮﻃﺎن ﻋﻨﻖ اﻟﺮﺣﻢ ﺟﺮﻋﺔ‬
 ---------------
(Female) Intramuscular Injection * HPV Vaccine 3rd dose
‫ ﻋﺎﻣﺎ وﻣﺎ ﻓﻮق ﺳﺘﺤﺘﺎج ﻟﺜﻼﺛﺔ ﺟﺮﻋﺎت ﻣﻦ اﻟﻠﻘﺎح‬15 ‫ أﻣﺎ إذا ﻛﺎﻧﺖ اﻟﻄﺎﻟﺒﺔ‬،‫ ﻋﺎﻣﺎ ﺳﺘﺤﺘﺎج ﻟﺠﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎح اﻟﻮﻗﺎﻳﺔ ﻣﻦ ﺳﺮﻃﺎن ﻋﻨﻖ اﻟﺮﺣﻢ‬15‫إذا ﻛﺎن ﻋﻤﺮ اﻟﻄﺎﻟﺒﺔ أﻗﻞ ﻣﻦ‬ *
*If student is below 15 years old, two doses of HPV Vaccine is required. but if student is 15 years old and more three doses of HPV vaccine will be required

 I agree to give my son/ daughter vaccines which are mentioned above ‫ اﺑﻨﺘﻲ اﻟﻠﻘﺎﺣﺎت اﻟﻤﺸﺎر إﻟﻴﻬﺎ أﻋﻼه‬/‫ أواﻓﻖ ﻋﻠﻰ إﻋﻄﺎء اﺑﻨﻲ‬

 I disagree with my child being vaccinated because: :‫ اﺑﻨﺘﻲ ﻫﺬه اﻟﻠﻘﺎﺣﺎت‬/‫ ﻻ أواﻓﻖ ﻋﻠﻰ اﻋﻄﺎء اﺑﻨﻲ‬

 My child has been vaccinated before with the above marked booster ‫ ﺗﻠﻘﻴﺤﻬﺎ ﺳﺎﺑﻘﺎ ً ﺑﺎﻟﺠﺮﻋﺔ اﻟﻤﻨﺸﻄﺔ اﻟﻤﺸﺎر إﻟﻴﻬﺎ أﻋﻼه‬/‫ اﺑﻨﺘﻲ ﻗﺪ ﺗﻢ ﺗﻠﻘﻴﺤﻪ‬/‫ ﻛﻮن اﺑﻨﻲ‬
dose; (please send a document proving that). (‫)ﻳﺮﺟﻰ إرﺳﺎل ﻣﺎ ﻳﺜﺒﺖ ذﻟﻚ إﻟﻰ ﻋﻴﺎدة اﻟﻤﺪرﺳﺔ‬
 My child has a medical condition which prevents him/ her from ‫ ﻟﻮﺟﻮد ﻣﻮاﻧﻊ ﻃﺒﻴﺔ ﻟﻠﺘﻠﻘﻴﺢ ﺣﺎﻟﻴﺎ ً )ﻳﺮﺟﻰ إرﺳﺎل إﻗﺮار ﻣﻦ ﻗﺒﻠﻜﻢ أو ﻣﻦ ﻗﺒﻞ اﻟﻄﺒﻴﺐ‬
being vaccinated now (please send a letter written by you or doctor
(‫ ﻣﻤﺮﺿﺔ اﻟﺼﺤﺔ اﻟﻤﺪرﺳﻴﺔ‬/‫اﻟﻤﻌﺎﻟﺞ إﻟﻰ ﻣﻤﺮض‬
explaining the medical condition to the school nurse)
............................................................(‫ أﺧﺮى )اذﻛﺮ‬
 Others (Specify)………………………………………………………
Parent’s / Guardian’s Name : :‫ اﻟﻮﺻﻲ اﻟﺸﺮﻋﻲ‬/‫اﺳﻢ وﻟﻲ اﻷﻣﺮ‬
Relation : :‫ﺻﻠﺔ اﻟﻘﺮاﺑﺔ‬
Signature Parent’s / Guardian’s: :‫ اﻟﻮﺻﻲ اﻟﺸﺮﻋﻲ‬/‫ﺗﻮﻗﻴﻊ وﻟﻲ اﻷﻣﺮ‬
Date : Tel : : ‫رﻗﻢ اﻟﻬﺎﺗﻒ‬ :‫اﻟﺘﺎرﻳﺦ‬
.‫ وﻓﻲ ﺣﺎل وﺟﻮد اﺳﺘﻔﺴﺎر اﻟﺮﺟﺎء اﻻﺗﺼﺎل ﺑﻤﻤﺮض أو ﻃﺒﻴﺒﺔ اﻟﻤﺪرﺳﺔ‬،‫ وﻻ ﻳﺴﻤﺢ ﻟﻠﻄﺎﻟﺐ ﺑﺘﻌﺒﺌﺘﻪ أو اﻟﺘﻮﻗﻴﻊ ﻋﻠﻴﻪ‬،ً‫ ﻳﻌﺒﺄ ﻫﺬا اﻟﻨﻤﻮذج ﻣﻦ ﻗﺒﻞ وﻟﻲ اﻷﻣﺮ أو اﻟﻮﺻﻲ اﻟﺸﺮﻋﻲ ﺣﺼﺮا‬:‫ﻣﻼﺣﻈﺔ‬

ID Issue# Issue Date Effective Date Revision Date Page#

CP_6.2.13_F02 01 Jan 01, 2019 Mar 01, 2019 Jan 01, 2021 1/1

 
                                  

 
School Immunization Consent Form ‫ﻧﻤﻮذج اﻟﻤﻮاﻓﻘﺔ ﻋﻠﻰ إﻋﻄﺎء اﻟﻠﻘﺎﺣﺎت اﻟﻤﺪرﺳﻴﺔ‬

Please note: Only Parent or Guardian fills this form. The student is not allowed to fill it this form or sign it. If there is any further queries, please contact the School Nurse
or Doctor.

ID Issue# Issue Date Effective Date Revision Date Page#

CP_6.2.13_F02 01 Jan 01, 2019 Mar 01, 2019 Jan 01, 2021 2/1