Refusal to Vaccinate Child’s Name Child’s ID# Parent’s/Guardian’s Name My child’s doctor/nurse, , ■ That some vaccine-preventable diseases are common in other has advised me that my child (named above) should receive the countries and that my unvaccinated child could easily get one following vaccines: of these diseases while traveling or from a traveler. ■ If my child does not receive the vaccine(s) according to the Recommended Declined medically accepted schedule, the consequences may include ■ Hepatitis B vaccine ■ – Contracting the illness the vaccine is designed to prevent ■ Diphtheria, tetanus, acellular pertussis ■ (the outcomes of these illnesses may include one or more (DTaP or Tdap) vaccine of the following: certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, ■ Diphtheria tetanus (DT or Td) vaccine ■ meningitis, seizures, and deafness; other severe and ■ Haemophilus influenzae type b (Hib) vaccine ■ permanent effects from these vaccine-preventable ■ Pneumococcal conjugate or polysaccharide vaccine ■ diseases are possible as well). – Transmitting the disease to others (including those too ■ Inactivated poliovirus (IPV) vaccine ■ young to be vaccinated or those with immune problems), ■ Measles-mumps-rubella (MMR) vaccine ■ possibly requiring my child to stay out of child care or school ■ Varicella (chickenpox) vaccine ■ and requiring someone to miss work to stay home with my child during disease outbreaks. ■ Influenza (flu) vaccine ■ ■ My child’s doctor and the American Academy of Pediatrics, ■ Meningococcal conjugate or polysaccharide vaccine ■ the American Academy of Family Physicians, and the Centers ■ Hepatitis A vaccine ■ for Disease Control and Prevention all strongly recommend ■ Rotavirus vaccine ■ that the vaccine(s) be given according to recommendations. ■ Human papillomavirus (HPV) vaccine ■ Nevertheless, I have decided at this time to decline or defer the vaccine(s) recommended for my child, as indicated above, by check- ■ Other ■ ing the appropriate box under the column titled “Declined.” I know that failure to follow the recommendations about vaccination may I have been provided with and given the opportunity to read each endanger the health or life of my child and others with whom my Vaccine Information Statement from the Centers for Disease Control child might come into contact. I therefore agree to tell all health care and Prevention explaining the vaccine(s) and the disease(s) it pre- professionals in all settings what vaccines my child has not received vents for each of the vaccine(s) checked as recommended and which because he or she may need to be isolated or may require immediate I have declined, as indicated above. I have had the opportunity to medical evaluation and tests that might not be necessary if my child discuss the recommendation and my refusal with my child’s doctor had been vaccinated. or nurse, who has answered all of my questions about the recom- I know that I may readdress this issue with my child’s doctor or mended vaccine(s). A list of reasons for vaccinating, possible health nurse at any time and that I may change my mind and accept consequences of non-vaccination, and possible side effects of each vaccination for my child any time in the future. vaccine is available at www.cdc.gov/vaccines/pubs/vis/default.htm. I acknowledge that I have read this document in its entirety and I understand the following: fully understand it. ■ The purpose of and the need for the recommended vaccine(s). ■ The risks and benefits of the recommended vaccine(s). Parent/Guardian Signature: Date: Witness: Date: I have had the opportunity to rediscuss my decision not to vaccinate my child and still decline the recommended immunizations. Parent’s Initials: Date: Parent’s Initials: Date: Copyright © 2013 9-80/0 Parental Refusal to Accept Vaccination: Resources for Pediatricians Reliable Immunization Resources for Parents The following are some of the resources available to help pediatricians Web Sites develop a productive dialogue with vaccine-hesitant parents and answer 1. Centers for Disease Control and Prevention (CDC) Vaccine questions about vaccine risks and benefits: Information Statements Web Sites Provide possible health consequences of non-vaccination and possible side efects of each vaccine. 1. AAP Childhood Immunization Support Program (CISP) www.cdc.gov/vaccines/pubs/vis/default.htm Information for providers and parents. 2. AAP Childhood Immunization Support Program (CISP) www.aap.org/immunization Information for providers and parents. www2.aap.org/immunization/pediatricians/refusaltovaccinate.html www.aap.org/immunization 2. Immunization Action Coalition (IAC) 3. Why Immunize? Te IAC works to increase immunization rates by creating and distrib- uting educational materials for health professionals and the public that A description of the individual diseases and the benefts expected from enhance the delivery of safe and efective immunization services. Te vaccination. IAC “Unprotected People Reports” are case reports, personal testimonies, www2.aap.org/immunization/families/faq/whyimmunize.pdf and newspaper and journal articles about people who have sufered or 4. Pennsylvania Immunization Education Program of Pennsylvania Chapter, AAP died from vaccine-preventable diseases. Includes answers to common vaccine questions and topics, such as www.immunize.org/reports addressing vaccine safety concerns; evaluating anti-vaccine claims; 3. Centers for Disease Control and Prevention (CDC) National sources of accurate immunization information on the Web; and Immunization Program talking with parents about vaccine safety. Information about vaccine safety. www.paiep.org www.cdc.gov/vaccines/hcp.htm 5. CDC For Parents: Vaccines for Your Children 4. National Network for Immunization Information (NNii) Information about vaccine safety. Includes information to help answer patients’ questions and provide www.cdc.gov/vaccines/parents/index.html the facts about immunizations. 6. National Network for Immunization Information (NNii) http://www.immunizationinfo.org/professionals Includes information to help answer patients’ questions and provide 5. Vaccine Education Center at Children’s Hospital of Philadelphia the facts about immunizations. Information for parents includes “Vaccine Safety FAQs” and www.immunizationinfo.org/parents “A Look at Each Vaccine.” 7. Vaccine Education Center at Children’s Hospital of Philadelphia www.vaccine.chop.edu Information for parents includes “Vaccine Safety FAQs” and 6. Institute for Vaccine Safety, Johns Hopkins Bloomberg School of “A Look at Each Vaccine.” Public Health www.vaccine.chop.edu Provides an independent assessment of vaccines and vaccine safety 8. Institute for Vaccine Safety, Johns Hopkins Bloomberg School to help guide decision-makers and educate physicians, the public, of Public Health and the media about key issues surrounding the safety of vaccines. Provides an independent assessment of vaccines and vaccine safety www.vaccinesafety.edu to help guide decision-makers and educate physicians, the public, 7. Immunize Canada and the media about key issues surrounding the safety of vaccines. Immunize Canada aims to meet the goal of eliminating vaccine- www.vaccinesafety.edu preventable disease through education, promotion, advocacy, and 9. Immunize Canada media relations. It includes resources for parents and providers. Immunize Canada aims to meet the goal of eliminating vaccine- www.immunize.cpha.ca/en/default.aspx preventable disease through education, promotion, advocacy, and 8. Sample ofce policy/letter to parents about refusal to vaccinate media relations. It includes resources for parents and providers. Journal Articles http://immunize.cpha.ca/en/default.aspx 1. Oft PA, Jew RK. Addressing parents’ concerns: do vaccines contain 10. Vaccinate Your Baby harmful preservatives, adjuvants, additives, or residuals? Pediatrics. Tis Every Child By Two site serves as a central resource of vaccine 2003;112(6 Pt 1):1394–1397 information for parents. Te site links to the latest research and studies 2. Oft PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do about vaccines, an interactive timeline on the benefts of vaccines, multiple vaccines overwhelm or weaken the infant’s immune system? information about vaccine safety and ingredients, and the importance Pediatrics. 2002;109(1):124–129 of adhering to the recommended schedule. 3. Diekema DS, American Academy of Pediatrics Committee on Bioethics. www.vaccinateyourbaby.org Responding to parental refusals of immunization of children. Pediatrics. Books 2005;115(5):1428–1431 1. American Academy of Pediatrics. Immunizations and Infectious Diseases: Books An Informed Parent’s Guide. Fisher MC, ed. Elk Grove Village, IL: 1. American Academy of Pediatrics. Red Book: 2012 Report of the American Academy of Pediatrics; 2006 Committee on Infectious Diseases. Pickering LK, Baker CJ, Long SS, 2. Myers MG, Pineda D. Do Vaccines Cause Tat?! A Guide for Evaluating Kimberlin DW, eds. 29th ed. Elk Grove Village, IL: American Academy Vaccine Safety Concerns. Galveston, TX: Immunizations for Public of Pediatrics; 2012 Health; 2008 2. Marshall GS. Te Vaccine Handbook: A Practical Guide for Clinicians. 3. Oft PA. Autism’s False Prophets: Bad Science, Risky Medicine, and the 5th ed. West Islip, NY: Professional Communications, Inc; 2015 Search for a Cure. New York, NY: Columbia University Press; 2008 Handout 4. Oft PA. Deadly Choices: How the Anti-Vaccine Movement Treatens 1. Immunization Action Coalition. Reliable sources of immunization Us All. New York, NY: Basic Books; 2011 information: where to go to fnd answers! http://www.immunize.org/ 5. Mnookin S. Te Panic Virus: A True Story of Medicine, Science, catg.d/p4012.pdf. Accessed October 17, 2012 and Fear. New York, NY: Simon and Schuster; 2011 6. Oft PA, Moser CA. Vaccines and Your Child: Separating Fact from Fiction. New York, NY: Columbia University Press; 2011 Copyright © 2013 9-80/0.