Modified AAP Refusal of Vaccination Form

Consent Declined for Vaccines

Child’s Name ________________________________________

Child’s ID#____________________

Parent’s/Guardian’s Name(s)___________________________________________

My child’s health care provider ___________________, has advised me that my child (named above) should receive the following vaccines:

Vaccines:  Recommended and/or  Declined

Vaccine Recommended Declined Date
Hepatitis B Y/N Y/N __/__/__
DTaP Y/N Y/N __/__/__
DT or Td Y/N Y/N __/__/__
Haemophilus influenza type B  (Hib) Y/N Y/N __/__/__
Pneumococcal conjugate vaccine Y/N Y/N __/__/__
Polio vaccine (IPV) Y/N Y/N __/__/__
Measles, mumps, rubella MMR-II Y/N Y/N __/__/__
Varicella (chickenpox) Y/N Y/N __/__/__
Influenza (flu) Y/N Y/N __/__/__
Meningococcal Y/N Y/N __/__/__
Hepatitis A Y/N Y/N __/__/__
Rotavirus Y/N Y/N __/__/__
       
Other________________________ Y/N Y/N __/__/__
Total      _____ ___ ___ __/__/__

 

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) for which it is intended. I have had the opportunity to discuss this with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s).

 I understand the following:

● The intended purpose of the recommended vaccine(s)
● The risks and benefits of the recommended vaccine(s)
● If my child does not receive the vaccine(s), the consequences may include
- Contracting the illness the vaccine should prevent. (The outcomes of these illnesses may include one or more of the following: pneumonia, illness requiring hospitalization, death, brain damage, meningitis, seizures, and deafness. Other severe and permanent effects from these vaccine -preventable diseases are possible as well)
- Transmitting the disease to others
- The need for my child to stay out of child care or school during disease outbreaks

● If my child does receive the vaccine(s), the consequences may include:
-Contracting the illness the vaccine should have prevented
-Transmitting the disease to others
-Suffering from any of the adverse events listed in the package insert and possibly adverse events not
yet listed and/or associated with the vaccine. (the outcomes of these adverse events may include one or more of the following: illness requiring hospitalization, death, brain damage, meningitis, seizures, and deafness. Other severe and permanent effects from these vaccines are possible as well)
-Chronic illness and/or death

● My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given based on the information they have been given by the drug companies producing the vaccines.

I have declined consent for the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled “Declined.”

I know that I may re-address this issue with my health care provider at any time, and that I may change my mind as personal beliefs are subject to evolve and change over time.

I acknowledge that I have read this document in its entirety and fully understand it.

Parent/Guardian Signature ______________________________________

Date__/__/__

Witness___________________________________________  

Date__/__/__

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