Record of Vaccine Declination

I am the parent/guardian of the child named at the bottom of • I understand that if my child is not vaccinated and gets
this form. My healthcare provider has recommended that my infected, my child could develop serious complications.
child be vaccinated against the diseases indicated below. I These may include pneumonia, hospitalization, brain
have been given a copy of the Vaccine Information Statement damage, paralysis, seizures, deafness, and death.
(VIS) that explains the benefits and risks of receiving each of
• I understand that my child may be excluded from his or her
the vaccines recommended for my child. I have carefully
child care facility, school, sports events, or other organized
reviewed and considered all of the information given
activities during disease outbreaks. This means my child
to me. However, at this time I choose to refuse the vaccine(s)
and I could miss many days of school and/or work.
for my child that are shown in the table below. I have read
and acknowledge the following: • I understand that the American Academy of Pediatrics,
the American Academy of Family Physicians, and the
• I understand that vaccine-preventable diseases can
Centers for Disease Control and Prevention all
infect unvaccinated U.S. children and can result in
recommend preventing diseases through vaccination.
hospitalization and even death.
Vaccine I decline this
• I understand that vaccine-preventable infections that are VIS
Vaccine / Disease given
recommended by vaccination for
no longer common in the U.S. still occur around the world. ( )
doctor or nurse
(Dr./Nurse initials)
my child
(Initials of
An unvaccinated child can be infected while traveling, or parent/guardian)

through direct or indirect contact with a traveler. COVID-19

Diphtheria-tetanus-pertussis (DTaP)
• I understand that my unvaccinated child could spread
disease to another child who is too young to be Haemophilus influenzae type b (Hib)
vaccinated or to a person whose medical condition, Hepatitis A (HepA)
such as cancer, or immune system problems, prevents Hepatitis B (HepB)
them from being vaccinated. This could result in health
Human papillomavirus (HPV)
complications and even death for the other person.
Influenza
• I understand that if too many parents exempted their
Measles-mumps-rubella (MMR)
child from vaccination, these diseases would return to
our community in full force. Meningococcal ACWY (MenACWY)

Meningococcal B (MenB)
• I understand that my unvaccinated child may not be
protected by “herd” or “community” immunity (i.e., Pneumococcal conjugate (PCV)

protection that is the result of having most people in a Polio, inactivated (IPV)
population vaccinated against a disease). Rotavirus (RV)
• I understand that some vaccine-preventable diseases Tetanus-diphtheria (Td)
such as measles and pertussis are extremely infectious Tetanus-diphtheria-pertussis (Tdap)
and have been known to infect unvaccinated people
Varicella (Var)
living in highly vaccinated populations.

After discussion with my provider who

recommends these vaccines, I acknowledge
that I am declining to have my child child ’ s name date of birth

vaccinated against one or more diseases

listed above. I have placed my initials in parent / guardian signature date
the table above to indicate the vaccine(s)
I am declining. I understand that I can
change my decision in the future and doctor / nurse signature date
have my child vaccinated.

c o n t i n u e d o n t h e n ext p a ge

www.immunize.org/catg.d/p4059.pdf
FOR PROFESSIONALS www.immunize.org / FOR THE PUBLIC www.vaccineinformation.org Item #P4059 (4/17/2023)
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Additional Information for Healthcare Professionals about
Immunize.org’s “Record of Vaccine Declination”
Unfortunately, some parents will refuse to have their child receive important source that helped them make decisions about vaccinating
some vaccines. For healthcare providers who want to assure that these their child.4 Gust and colleagues found that the advice of their
parents fully understand the consequences of their decision, Immunize. children’s healthcare provider was the main factor in changing the
org has produced a form titled “Record of Vaccine Declination.” This minds of parents who had been reluctant to vaccinate their children
form facilitates and documents the discussion that a healthcare or who had delayed their children’s vaccinations.5 Vaccine-hesitant
professional can have with parents about the risks of not having their parents who felt satisfied with their pediatricians’ discussion of
child vaccinated before the child leaves the medical setting. vaccination most often chose vaccination for their child.6

Your use of the “Record of Vaccine Declination” demonstrates the All parents and patients should be informed about vaccination risks
importance you place on timely and complete vaccination, focuses the and benefits by following these steps:
parents’ attention on the unnecessary risk for which they are accepting
• Give the appropriate Vaccine Information Statement (VIS) to the
responsibility, and may encourage a vaccine-hesitant parent to accept
parent or legal representative before each vaccine is given. This is
your recommendations. According to an American Academy of Pediat-
required by federal law.
rics (AAP) survey on immunization practices, almost all pediatricians
reported that when faced with parents who refuse vaccination, they • When parents refuse a recommended vaccine, document that
attempt to educate parents regarding the importance of immunization you provided the VIS(s), and have the parent sign the “Record of
and document the refusal in the patient’s medical record.1 Vaccine Declination.”

Your recommendation can make a difference. Vaccine recommendations • Revisit the vaccination discussion at each subsequent visit. Flag the
from the child’s healthcare provider can strongly influence a parent’s charts of fully or partially unvaccinated children as a reminder to
final vaccination decision.2 Most parents trust their children’s doctor revisit the vaccination discussion. Flagging also alerts the team
for vaccine-safety information (76% endorsed “a lot of trust”), about missed vaccinations when evaluating an ill child, especially
according to researchers from the University of Michigan.3 Similarly, one who has a fever without a clear source.
analyses of the 2009 HealthStyles Survey found that the vast majority
of parents (81.7%) name their child’s doctor or nurse as the most

What do others say about documentation include a requirement for parents to complete a form that explicitly
of vaccine declination? states the grounds for the exemption and requires them to
acknowledge awareness of the disease-specific risks associated
American Academy of Pediatrics (AAP): “The AAP encourages with not vaccinating their child(ren).”8
documentation of the health care provider’s discussion with parents
National Association of County and City Health Officials (NACCHO):
about the serious risks of what could happen to an unimmunized
NACCHO encourages various steps be taken to limit non-medical
or under-immunized child....For parents who refuse one or more
exemptions to school immunization requirements. “For individuals
recommended immunizations, document your conversation and the
requesting [non-medical] exemptions, (1) require documentation from
provision of the VIS(s), have a parent sign the Refusal to Vaccinate
a medical provider regarding the refusal to vaccinate and consultation
form, and keep the form in the patient’s medical record.”7
pertaining to risks; (2) require consultation and signature by the local
Association of State and Territorial Health Officials (ASTHO): “To health department for non-medical exemptions; or (3) implement
address the risk of VPD [vaccine-preventable disease], states should mandatory education sessions and require acknowledgement of risk
consider adopting more rigorous standards for non-medical vaccine or notarized documentation of non-medical exemptions for parents,
exemptions that require parents to demonstrate that they have made guardians, or student 18 years and older about the importance of
a conscious, concerted, and informed decision in requesting these immunization and the impact of refusing immunizations.”9
exemptions for their children. An example of such a standard might

references

1. Diekema DS, and the Committee on Bioethics. Responding 4. Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, 7. AAP. Immunization Information, accessed on April 2, 2023 at
to parental refusals of immunization of children. Pediatrics. and information sources reported by parents of young chil- https://downloads.aap.org/DOPCSP/SOID_RTV_form_01-
2005;115:1428-1431. http://pediatrics.aappublications.org/ dren: results from the 2009 HealthStyles survey. Pediatrics. 2019_English.pdf.
content/115/5/1428 2011; 127 Suppl 1:S92-9. www.ncbi.nlm.nih.gov/pubmed/ 8. ASTHO. Permissive State Exemption Laws Contribute
21502253 to Increased Spread of Disease. 21 May 2011. Accessed on
2. Brewer NT, Fazekas KI. Predictors of HPV vaccine accept-
ability: a theory-informed, systematic review. Prev Med. 2007 5. Gust DA, Darling N, Kennedy A, Schwartz B. Parents with Nov 20, 2020 at www.astho.org/Programs/Immunization/
Aug-Sep;45[2-3]:107-14. www.ncbi.nlm.nih.gov/ doubts about vaccines: which vaccines and reasons why. Vaccine-Refusal-Brief/
pubmed/17628649 Pediatrics. 2008;122:718-25. www.ncbi.nlm.nih.gov/pubmed/ 9. NACCHO. Statement of Policy: School and Child Care
18829793 Immunization Requirements. Approved by NACCHO Board
3. Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM.
Sources and perceived credibility of vaccine-safety informa- 6. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe of Directors on February 24, 2016; Updated July 2019.
tion for parents. Pediatrics. 2011 May;127 Suppl 1:S107-12. ES. Qualitative analysis of mothers’ decision-making about Accessed on April 2, 2023 at www.naccho.org/uploads/
www.ncbi.nlm.nih.gov/pubmed/21502236 vaccines for infants: the importance of trust. Pediatrics. 2006; downloadable-resources/16-01-School-and-Child-Care-
117[5]:1532-41. www.ncbi.nlm.nih.gov/pubmed/16651306 Immunization-Requirements.pdf.

www.immunize.org/catg.d/p4059.pdf / Item #P4059 (4/17/2023)