Refusal to Vaccinate
CHILD’S/ADULT WORKER’S NAME
CHILD’S PARENT’S/GUARDIAN’S NAME
I have had the opportunity to discuss the recommended vaccines and my refusal with my/my child’s doctor or nurse,
who has answered all of my questions about the recommended vaccine(s). I have had the opportunity to review a list of
reasons for vaccinating, possible health consequences of non-vaccination, and possible side eﬀects of each vaccine on
the Web site of the Centers for Disease Control and Prevention at www.cdc.gov/vaccines/pubs/vis/default.htm.
I still decline the following nationally recommended immunizations:
Name of Vaccine Check if Recommended Declined or Delayed;
for Age and Risk Initials and Date
Diphtheria, tetanus, acellular pertussis (DTaP or Tdap)
Diphtheria, tetanus (DT or Td)
Haemophilus influenzae type b (Hib)
Pneumococcal conjugate or polysaccharide
Inactivated poliovirus (IPV)
Meningococcal conjugate or polysaccharide
Human papillomavirus (HPV)
I understand the following:
• The purpose of and the need for the recommended vaccine(s).
• The risks and beneﬁts of the recommended vaccine(s).
• That some vaccine-preventable diseases are common in other countries and that unvaccinated people could easily
get one of these diseases while traveling or from a traveler who comes to anyplace in my community.
• Without receiving the vaccine(s) according to the medically accepted schedule, the consequences may include
getting the disease that could increase the risk of certain types of cancer, pneumonia, illness requiring hospitaliza-
tion, death, brain damage, paralysis, meningitis, seizures, and deafness, as well as other severe and permanent
• Spreading the disease to others (including those too young to be vaccinated or those with immune problems),
possibly requiring staying at home for a prolonged time.