Edit, Download, and Sign the Record of Vaccine Declination Form for Parents
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How do I fill this out?
To fill out this form, provide your child’s name, date of birth, and indicate which vaccines you are declining. Both the parent/guardian and the healthcare provider must sign the form. Ensure all information is accurate before submission.
How to fill out the Record of Vaccine Declination Form for Parents?
1
Enter child's name and date of birth.
2
Read the statements regarding vaccination risks and implications.
3
Indicate which vaccines you are declining by placing your initials.
4
Sign the form as the parent/guardian.
5
Ensure the healthcare provider signs the form.
Who needs the Record of Vaccine Declination Form for Parents?
1
Parents/guardians who choose to decline vaccination for their child.
2
Healthcare providers documenting parental refusal of vaccination.
3
Schools or childcare facilities requiring vaccination records.
4
Public health departments tracking vaccination refusal data.
5
Legal entities needing proof of parental decision regarding vaccination.
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You can easily edit this PDF on PrintFriendly by accessing the file through our PDF editor tool. Make necessary edits such as adding your child’s name and initials where required. Save your changes instantly within the editor.
1
Open the PDF file on PrintFriendly's PDF editor.
2
Enter your child’s name and date of birth.
3
Indicate which vaccines are being declined by initialing.
4
Add signatures using the e-signature tool.
5
Download the edited PDF or share it directly.
What are the instructions for submitting this form?
To submit this form, ensure that all required fields are accurately filled out. The parent or guardian must sign the form, and the healthcare provider must also sign. You can submit the form via email, fax, or physical mail to your healthcare provider’s office or relevant public health department. Always keep a copy for your records. For electronic submission, use the online submission form available through your healthcare provider’s website if available.
What are the important dates for this form in 2024 and 2025?
This form should be updated and reviewed in line with immunization schedules for 2024 and 2025. Ensure to check for any changes in vaccination policies or recommendations.
What is the purpose of this form?
The purpose of this form is to document a parent’s or guardian’s decision to refuse certain recommended vaccinations for their child. It outlines the potential risks and consequences of not vaccinating and requires acknowledgment of these risks by the parent/guardian. This form also serves as a record for healthcare providers, schools, and public health authorities.
Tell me about this form and its components and fields line-by-line.
- 1. CHILD'S NAME: Enter the full name of the child.
- 2. DATE OF BIRTH: Enter the date of birth of the child.
- 3. Vaccine/Disease: List of vaccines and corresponding diseases.
- 4. PARENT/GUARDIAN SIGNATURE: Signature of the parent or guardian.
- 5. DOCTOR/NURSE SIGNATURE: Signature of the healthcare provider recommending the vaccines.
- 6. VIS given: Indicate if the Vaccine Information Statement was given.
- 7. Vaccine recommended by doctor or nurse: Initials of the doctor or nurse recommending the vaccine.
- 8. I decline this vaccination for my child: Parent or guardian's initials indicating refusal of each vaccine.
- 9. DATE: The date the form is filled and signed.
What happens if I fail to submit this form?
Failure to submit this form can have serious implications for the child and community. There may be risks such as exclusion from school or activities during disease outbreaks.
- Health Risks: Unvaccinated children are at a higher risk of contracting and spreading vaccine-preventable diseases.
- Exclusion from Activities: The child may be excluded from school, sports, or other activities during outbreaks.
- Legal Implications: Failure to comply with school or public health requirements may lead to legal consequences.
How do I know when to use this form?
- 1. Parental Decision: Parents choosing to refuse vaccinations for their child.
- 2. Healthcare Documentation: Healthcare providers documenting the refusal of vaccinations.
- 3. School Requirements: Schools requiring formal documentation of vaccine refusal.
- 4. Public Health Tracking: Public health departments tracking vaccination refusal data.
- 5. Legal Proof: Providing legal proof of parental decision regarding vaccinations.
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What information is required on this form?
You need to provide your child’s name, date of birth, and the vaccines you are declining.
Do both parent and healthcare provider need to sign?
Yes, both signatures are required on the form.
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