No, I need to book my GROUP 1 Whooping Cough (PERTUSSIS) Jab

Name*
Date of birth*
Date Format: DD slash MM slash YYYY
Email*
Current department*
e.g. Maternity
Current area of work*
e.g. Central Delivery Suite
Current role*
e.g. Midwife
Consent*
I agree that:
I understand the trust online booking system will be “self-service”, with appointments at five minute intervals to maintain social distancing. The vaccines will be administered in the JCUH Atrium on a Tuesday and Thursday and at FHN by arrangement.

I understand the Pertussis vaccines also protect against Tetanus and Diphtheria, they are thiomersal-free (do not contain mercury) and are inactivated (do not contain live organisms) therefore cannot cause the diseases against which they protect.

I understand the vaccines should not be given to those who have had:

● a confirmed anaphylactic reaction to a previous dose of a pertussis containing vaccine, or

● a confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B (which may be present in trace amounts).

I understand my vaccine will be an intramuscular injection in the deltoid muscle of my right or left arm as per my preference.

I understand the details of my Pertussis vaccination will be recorded on the Occupational Health Service electronic notes system, COHORT, and included in my list of vaccinations and immunisations
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