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CARD System for Vaccination

The CARD System provides strategies that can be used to help cope before and during vaccination and needle procedures. The system consists of resources such as videos, handouts and activities that will help to prepare for a vaccination or needle procedure.

The CARD toolkits on this page have been developed to facilitate the implementation of the CARD System in school clinics. The toolkits have also been categorized based on the target audience. In the CARD System, the immunizers, school staff, parents/guardians and students each play a role and specific resources for each audience have been developed. In order to best utilize these resources, the school immunization team should ensure each toolkit has been effectively shared with the targeted audience. 

On this page

Health Care Provider Toolkit

The CARD System is a vaccination delivery framework that systematically integrates evidence based strategies proven to reduce pain, fear and stress-related responses in vaccine recipients. This toolkit is a reference guide for health care providers implementing the CARD System in school settings. 

Watch the CARD Integration Guide for Vaccinations video. 

‎Click on the image below to enlarge.


‎Integration of the CARD system in your practice requires preparation prior to the day of the vaccination, implementation of strategies on the day of the vaccination and evaluation of your work after the clinic has ended.

The CARD 4E Model (Education, Environment, Engagement and Evaluation), provides immunizers with tools and strategies to effectively deliver the CARD system. These strategies may involve students, parents/guardians and the school staff. In addition, some of these may need to be implemented before vaccination day and some during or after vaccination day. 

The CARD for Vaccination – Logic Model provides a snapshot of resources, activities and expected outputs of CARD integration in the immunization program. This resource can be utilized at the local or regional level to evaluate the implementation of the CARD System in the immunization program.


Resources for CARD System Integration

Education: this includes education for healthcare providers as well as students, parents and school staff. Provide these resources prior to vaccination day to help ensure everyone is aware of how to play their cards for a better experience.
Coordinating with school staff prior to the vaccination day will help with implementing CARD. An agreement can be established with the school to ensure everything is in place for vaccination day. See the document below as an example: 
The following templates can be used for communications with students, families and staff. Note these are generic templates and can be adapted per your organizational policies and to meet your specific workflows:
Planning for Vaccination Day: utilize the CARD Vaccination Planning Checklist to ensure you have all the logistical resources you require for successful implementation.

If it is the first time you are implementing the CARD System at a school clinic, it may require modifications to your current workflows and coordination among your team. Customizing CARD provides suggestions on how to implement the CARD system in your practice. 

Checklist: review the CARD Vaccination Day Checklist

Supporting students in using their CARDs:
Follow your organizational policies and collaborate with the school to consider the best way to evaluate the CARD system in your setting.

Evaluation of the CARD system can be done in a structured manner such as completion of surveys by students, parents/guardians and the school staff. For instance as the students are waiting in the post-immunization observation area, they can complete a quick survey. 

Feedback may also be obtained informally; however, this does not provide sufficiently detailed information to inform improvements in practice. Most people just say ‘it was ok’ to general questions. Ask specific questions, e.g., ‘Tell me how afraid you were from 0 (not afraid) to 10 (most afraid).'

With the school staff, evaluation can be completed in a form of debrief. 

Public health staff can review the feedback of others (students and school staff) in a debrief session after the clinic. It is also helpful to debrief with the immunizers to better understand what worked well and how to improve the use of the CARD system for next time. This can inform future improvements to vaccination service delivery.

Evaluation is a crucial step in the CARD system as it would create opportunities for improvement and revisions of the current workflows.

The following survey templates can be utilized if your organization chooses to systematically evaluate the implementation of the CARD system in their school clinics. Note these can be adapted to meet your organization’s policies and needs:

School Staff Toolkit

Many Canadian students receive their routine vaccines at school. Delivery of vaccinations through schools helps to ensure students receive their vaccinations on time and are protected against serious vaccine preventable diseases.

Some students may experience high levels of anxiety and fear at school clinics due to an underlying fear of needles or fear contagion (when fear is spread among individuals). The CARD System is an evidence-based practice that supports students to develop a coping strategy to manage their fear and anxiety during vaccination injection pain. Staff at schools play a crucial role in ensuring the CARD System is effectively implemented. Review the resources enclosed in this toolkit to learn how you can support students in using CARDs.

The CARD System (Comfort, Ask, Relax, Distract) provides groups of strategies that can be used before and during vaccination to make the experience a more positive one for students. To learn more, review the resource "Improving the Vaccination Experience: A guide for school staff".


Watch the video "School vaccinations - Improving the vaccination experience at school" to learn how the CARD System was implemented in Niagara Region school clinics.‎



Kids Boost Immunity has a free online lesson on How to Handle Your Shots Like a Champ. There is also a lesson plan for teachers. Allocating class time for this lesson prior to the vaccination day will help to prepare students to use the CARDs System. The best time to do this lesson is when vaccine consents forms go home. ‎ For support or additional information on this course, connect with the public health nurse/school nurse.


Teachers and staff at school can support students by sharing the CARD resources before the vaccination day. This would allow students to review these and ask their questions in time for their vaccination day.

The resources that can be shared with students include:‎



Kids Boost Immunity Lesson: How to Handle Your Shots Like a Champ

Planning fun activities and avoiding stressful events such as tests and field trips can support students to better cope on vaccination day. 

Review the Checklist for school staff to learn how you can better supports students on their vaccination day. 

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How the immunization clinic is set-up can trigger and impact students’ anxiety about receiving vaccines. Factors such as poor ventilation, long line-ups and watching peers receiving their vaccines can increase students’ anxiety. School staff can support students by providing well ventilated space with separate waiting areas for before and after vaccination. 

School staff can also utilize CARD posters to create distractions for students as they are waiting to receive their vaccinations.‎




Parents/Guardians Toolkit

Many parents/guardians have concerns about their children’s pain and fear of vaccination. At times this may result in delays in receiving recommended vaccines and put children at risk of developing vaccine preventable diseases. This toolkit will introduce parents/guardians to the CARD System and provide resources on how they can help prepare their children for their vaccination.  

The CARD System (Comfort, Ask, Relax, Distract) provides groups of strategies that can be used before and during vaccination to make the experience a more positive one for you and your child. To learn more, review the resource "Improving the Vaccination Experience: What is CARD for parents and caregivers". 

Click on the image to enlarge.‎


Watch the video "What if my teen has a problem with needles?" to learn how CARD can prepare children for their vaccine.‎


Topical anesthetics (numbing creams or patches) can be applied to the area(s) where the vaccination will be given to temporarily numb the skin and reduce pain at the injection site. These products can be purchased at your local pharmacy without a prescription. The cream or patch needs to be put on 30-60 minutes before the immunization, depending on the product. If you'd like to use these products at a school clinic, please contact your local health unit or community health centre and speak with a nurse. The nurse will provide you with additional information on where to apply the numbing cream or patch.

Review the resource "Improving the Vaccination Experience: Using numbing cream to reduce pain" for more information.‎ 

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Your child may have questions about their vaccination. Learn how to navigate these conversations in ways that invite your child’s participation and promote coping and positive experiences. For more information, review the resource "Improving the Vaccination Experience: What parents and caregivers can say".

Review the CARD Student Toolkit with your child. This resource has been developed to support children in preparing for their vaccination. How to Handle Your Shots Like a Champ is a self-paced series of lessons that explains to children why they get vaccines in school and ways to be less anxious on vaccination day using CARD. Your child may need your help in accessing this resource.

Practice CARD games that can be used on vaccination day.

Help your child prepare their CARDs for the vaccination day by completing the CARD System Activity.‎

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Student Toolkit

Vaccination is one of the most important tools that helps us stay healthy and prevent illness. Most vaccines are given by needle injection and this can cause some people to feel pain and be afraid. Most people will experience pain during needle injections but there are things you can do to reduce pain and fear and have a better experience. 

This toolkit will show you how to use the CARD System (Comfort, Ask, Relax, Distract) to make your vaccination experience more positive. Choose what CARDs you want to play to reduce the fear and pain from needles. 

Watch the video "The CARD System: Play your power CARD" to learn more about the CARD System.‎


Review this handout to learn what to do at each step of the CARD System:
C - Comfort
A - Ask
R - Relax
D - Distract

How to Handle Your Shots Like a Champ lesson reviews how to use the CARD System to prepare for your vaccination day. ‎


Playing games can help you with distractions. Watch these YouTube Short Videos about the CARD game for kids.‎
Be ready to play your CARDs on vaccination day. Tell the nurse what you want to play. Select as many options as you need from the CARD checklist below. 

On vaccination day, bring your checklist and share it with nursing staff. It will let them know which CARDs you want to play. They will play with you.

Click on the image below to enlarge.


SOURCE: CARD System for Vaccination ( )
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