Please enter the Child's details below

Step 2 of 5

Child's Given Name

Child's Family name

Child's preferred Name (optional)

Child's Date of Birth

Child's Gender

Male

Female

Other

Not Stated

Child's Indigenous status

Aboriginal (Not Torres Strait Islander)

Torres Strait Islander

Aboriginal & Torres Strait Islander

Neither Aboriginal nor Torres Strait Islander

Not Stated

Is the child of South Sea Islander descent?

Yes

No

Child's Street Address

Child's Suburb

Child's Postcode

Please enter your details as parent, legal guardian or Approved Foster/Kinship carer below

Step 3 of 5

Your Given Name

Your Family name

Your Preferred Name (optional)

Your Date of Birth

Is your Address the same as the Child's?

Yes

No

Your Street Address

Suburb

Postcode

Mobile

Home Phone

Is your spoken language English?

Yes

No

Or another Language?

Do you require an interpreter?

Yes

No

Please answer the Pre-Screening questions below

Step 4 of 5

Does your child wear glasses?

None

Reading

Distance

Both

Was your child born prematurely (less than 37 weeks gestational age)?

Yes

No

Has your child seen an eye clinician in past 12 months?

Yes

No

Has anyone in your immediate family been prescribed patching or glasses as a child?

Yes

No

Do you have any concerns about your child's eyes?

Yes

No

Please provide some details (100 character limit)

Confirm consent

Step 5 of 5

The Children’s Health Queensland Hospital and Health Service (CHQ HHS) is bound by the Information Privacy Act 2009. The CHQ HHS is collecting your and your child’s personal information to indicate your preference for your child to participate in vision screening. The completed form and information, whether you consent or decline to participate, will be stored by the CHQ HHS and disclosure of the information may be required in certain circumstances such as when it is required by law, in connection with the patient’s ongoing care and treatment, or where you give prior consent.

I acknowledge that the results of my child’s screening test will be recorded on a secure database which assists with the follow up of children who require further testing or treatment.

Information from the database may be used for research purposes but names will not be used in any reports or published information.

Please check and answer the questions below

I consent to have my child’s vision screened

Yes

No

Primary School Nurse Health Readiness Program would like to contact you by email for selected screening communications, including reporting vision screening results. Where necessary, email encryption programs will be utilised for sensitive health information. An information sheet providing information about the risks and conditions of use can be found here.

I have read and understand the information provided in the Consent for Email Communication Patient/Guardian Information sheet

Yes

No

I consent to be contacted via email by the Primary School Nurse Health Readiness Program

Yes

No

Email address

Confirm Email address

I consent to information regarding my child’s vision screening results being provided to relevant personnel in the school and other health professionals in my child's health care

Yes

No

Consent Given By

Relationship to Child

In providing this information, I confirm that I am the child's parent or legal guardian and to my knowledge all the information provided is true and correct

Thank you

You have successfully completed this online form.

Parental Consent Portal

Parental Consent Form

Welcome to the Parental Consent Form Portal

First, please confirm your child's school

Please enter the Child's details below

Please enter your details as parent, legal guardian or Approved Foster/Kinship carer below

Please answer the Pre-Screening questions below

Confirm consent

Thank you