"refusal to vaccinate" form

iVillage Member
Registered: 10-20-2006
"refusal to vaccinate" form
Tue, 07-21-2009 - 9:15pm

Hi girls

Im hoping someone here can give me some info. You guys always are so knowledgeable and Ive come here quite a few times with questions, and you have always given me GREAT info (TIA!!)

Anyway - our ped is awesome. He allows us to selectively vaccinate our son and we did so on a slow, gentle schedule. He has not had MMR, Chicken Pox, Hep B, or flu vaccinations, and our ped is fine with it. He is 3 years old, in daycare and I have had no problems since DH and I signed a religious waiver for the vaccines he has not received.

Recently, at our last ped visit, the nurse gave us some static for not having the MMR and Chicken pox vax. While she says that she understands our ped is running the office, she gets a lot of heat from the state for allowing their office to not follow the CCD recommendations. (Im am SOOOOO tired of all the strong arming!). Anyway, last time we were there she asked if I could sign a refusal to vaccinate form - I did not, telling her I would take it home because I wanted my husband to look at it as well. She completely understood.

Well, do I HAVE to sign this form? Im thinking I dont want to - since the wording in it says that I KNOW the benefits of vaccination but STILL choose not to, knowing this could harm my child. Not liking that wording nor do I agree about the "benefits" and that I am putting my child in harms way. (I actually would rather sign something that says 4 shots at once into a tiny 2 month old is putting them in harms way!)

Any advice on how I get around this? Im just afraid they are going to tell me they cant treat our son, and I LOVE our Ped!

Thanks for any advice!!!!



iVillage Member
Registered: 12-27-2005
Wed, 07-22-2009 - 1:38am

ahhhhhhh the joys, huh?

Last fall (maybe?) I took one of the kids in for a sick visit and the nurse handed me the form.


Tracy - wife to Ron since 9/9/03, mom to college sophomore, Jason (18), high school Junior Chase
iVillage Member
Registered: 11-17-2007
Wed, 07-22-2009 - 7:12am
I would bring in a form for the nurse or DR to sign stating that you refuse to sign any of their forms on refusal to vaccinate. If you have an exemption in your sons file, there should be no further forms needed to sign.
Where did they get the "refusal to vaccinate" form from anyway? Did they make it up? And your son is 3? They waited 3 years to ask you to sign something? Sounds to me like some kind of ploy to have in kids files in case theres a child abuse case. That way the "state " can step in and say you are neglecting your child. NO, i would def NOT sign anything of the sort with your DR.
Its up to the Dr if he wants to stop treating your son, not the nurse. Nurses can be bullies who take fear mongering to the next level in a ped's office. And tell that nurse taking the heat from the state is part of her job. If she doesn't like it, she should not be in pediatrics.
iVillage Member
Registered: 10-20-2006
Wed, 07-22-2009 - 8:03am

Thank you SO much, ladies! I knew you would have advice for me :-)

We signed the waivers for DS's Daycare, but we have nothing on file at the Ped office, which is probably why she wanted us to sign. The heading on the form says its from the CDC - I dont think its something they made up, but probably something that the people from the state gave her, since they are not being compliant with info in the charts for those children who have not had all their vaccinations.

They didnt wait till he was 3 - when I first brought my son there (when he was a week old) they never, ever gave me a problem. Its funny, because the nurse Im talking about was actually very understanding in the beginning year. Its only recently that she COMPLETELY changed her tune (much to my surprise, actually) and I think its because of the lecturing she needs to hear from the state regarding the fact that the office is not being compliant. I cannot believe how they are doing this - even to the pediatrician's offices!!!!!!

Next time I go in I will bring a religious waiver form from the State signed by me and DH. Im sure that will suffice for them. Back when my son was 15 months old the nurse at his daycare gave us a hard time about him not having the MMR and chicken pox vaccines, and when we signed the waivers and gave them to her she STILL gave us a hard time (trying to think we didnt know the law - little did she know my DH IS a Dr - (Chiropractor) and knows the law VERY well). She completely backed down when we told her any additional questions could be addressed to our attorney. The director was fine with it and said as long as the waiver was in his file, she is in check with the State and all is good.

Thanks again!

iVillage Member
Registered: 12-27-2005
Wed, 07-22-2009 - 2:12pm
It's a form put out by the AAP.


Tracy - wife to Ron since 9/9/03, mom to college sophomore, Jason (18), high school Junior Chase
iVillage Member
Registered: 07-17-2005
Fri, 07-24-2009 - 6:24pm

I know the form, I signed it when Vannah was born and probably signed one when Brayden was born too. Does anyone know if I can take it back? Is there a form to negate the form? Can I claim stupidity? Ignorance?

Don't ask me why I signed it. I didn't care at the moment. At that time I had not yet learned about the unethical ways that a person can harm a parent...just because. It never occurred to me that the misuse of common sense can be obvious to everyone involved and the facts be ignored...Yes, I was that naive. It's just that the very thought of someone attacking our decision and then using the form against us was too *out there* to even fathom. Now, I know even the best of parents can be accused of harming their child. I worry that with Nobama's new health plan, we might see more of that. Has anyone tried to read that nonsense? I haven't yet, but I have read some comments of people who have, and no matter what side they vote on, they mostly agree that it makes no sense...

iVillage Member
Registered: 07-17-2005
Fri, 07-24-2009 - 6:33pm

Joey's a cutie-pie!

I hope you don't mind me asking but since your husband is a Chiropractor, I'm curious about which shots you chose and at what age.

I have read where people say that their state allows the religious exemption only if you deny ALL vaccines? I'm in GA and someone told me that it was true for GA too.

iVillage Member
Registered: 09-13-2008
Mon, 07-27-2009 - 12:49am
No one can force you to sign that form. But if someone gives you grief then give them this one. :)
iVillage Member
Registered: 07-17-2005
Mon, 07-27-2009 - 2:38pm
That's a good one!
iVillage Member
Registered: 10-20-2006
Tue, 07-28-2009 - 1:11pm


We did not do anything with live virus (nor will we). So, no chicken pox, no MMR. He did not have Hep B, no flu, (our ped doesnt even believe in that one) no Rotovirus (I think there is one for that?) Hep A - nope nope nope. No newer ones.

We did one shot at a time - DH was not crazy about DTaP, but I wanted it just because I do think there is still a threat of Pertussis - we did that one alone I believe when he was 4 months. All the others - HIB, Polio, we did just one at a time and I took my son back several times to have the additional injections. I waited a month or 2 - by 2 years old he was caught up on the ones we wanted him to have. If he had even a sniffle he did NOT get an injection.

Every state is different regarding the laws with religious exemption, so you will have to see what your state's law is, specifically. Its a shady area, since if you are claiming religious exemption, some think it should be for all and not some, however, it is ILLEGAL for them to ask you to disclose your religion, and there are some that are very specific regarding injecting (mixing) animal blood with human - using chicken embryos, or any of that stuff (basically the garbage that is in the live virus vaccinations). I actually spoke to a lawyer who has defended parents of children harmed by vaccines (I found him in the phone book and he was happy to answer my questions over the phone). They cannot ask you to disclose your religion, (doing so could harm YOU) so basically, they cannot determine if your religion allows for SOME and not others. Again, it depends on the state, and how strict they are with it. I live in CT, and basically all you need to do is sign the form (the parents) it does not need to be notorized, nor does it need to be signed by a priest, or any other religious establishment. A parent form is sufficient, as long as you realize if there is an outbreak at the school, you are required to leave your child home till the outbreak is over.

I believe it is definitely a gray area - right now for where I am, DS is in daycare and as long as I have the waiver in the file, they are fine with it. Im thinking I may get some static when I start him in public school, but I will fight it. You can always say that you changed your religious beliefs halfway through also. I would look into the laws in your State, specifically.

iVillage Member
Registered: 07-17-2005
Tue, 07-28-2009 - 1:59pm

"We did one shot at a time - DH was not crazy about DTaP, but I wanted it just because I do think there is still a threat of Pertussis - we did that one alone I believe when he was 4 months."

I understand how you feel about Pertussis. I came from a different point of view but now that my children are older, I just try to keep them healthy enough to get over Whooping Cough if they were to get it. I worried about it when they were infants because Whooping Cough can be fatal in that age-group especially. I gave my son the D (Diphtheria) and the T (Tetanus). (I started vaccines after age 2 and stopped at age 5, he's no longer vaccinated, my other child has never had a vaccine).

Because my brother had brain damage, caused by the Whole-Cell Pertussis vaccine, I didn't give either of my children a vaccine for Whooping Cough. Now all these years later and I have learned that the vaccine has shown to wane. :(

Here's the most recent example but there are stories like this across the country regarding Pertussis:

Whooping cough vaccine not as powerful as thought


The Atlanta Journal-Constitution

Sunday, March 22, 2009

A cluster of whooping cough cases among Cobb County elementary students is adding to concerns that an important vaccine isn’t as effective as it needs to be to stop the spread of disease.

Whooping cough, also called pertussis, is highly contagious and can cause serious illness among infants and very young children. But the vaccine is only about 85 percent effective and wears off over time, leaving a significant number of children and adults vulnerable to an infection that is more common than many realize, health officials said.

Eight-year-old Charlie Wood, shown studying with twin sister Emily, became ill with whooping cough. The Kincaid Elementary third-grader got sick despite being fully vaccinated. Emily didn’t get sick.

Of the 18 students in the recent Cobb cluster, 17 were properly immunized with five doses of DTaP vaccine, which protects against diphtheria, tetanus and pertussis, health officials said.

The Centers for Disease Control and Prevention has been studying the Cobb cases. While a better pertussis vaccine is needed, CDC officials said, the available shots are still the best protection against the disease and they reduce the severity of symptoms in people who are infected.

“Despite the fact that we routinely vaccinate against pertussis, pertussis is endemic. There’s lots of pertussis,” said Dr. Nancy Messonnier, director of CDC’s meningitis and vaccine preventable diseases branch.

But scientists are struggling to understand why reports of pertussis cases have risen dramatically since the 1980s. It may reflect more testing or diagnosis; it may reflect the cyclical nature of the disease. It’s even unclear how often clusters like the one in Cobb occur.

“We are frustrated by the fact that we don’t know,” Messonnier said.

About 10,000 cases and 20 infant deaths were reported in the United States last year, but some studies have suggested the number of people sickened each year may be closer to 300,000, CDC officials said.

Experts believe the disease is underdiagnosed and underreported in vaccinated school-age children and adults who often have milder symptoms and whose childhood shots have worn off. They believe that adolescents and adults are spreading the disease to vulnerable infants and children.

In an effort to stop this under-the-radar disease transmission, the CDC about four years ago began recommending that adults and adolescents get pertussis booster shots. The goal is to increase “herd immunity” — the more people who are immune, the harder it is for the disease to spread to those who aren’t protected because the vaccine didn’t work for them or because they aren’t vaccinated.

It’s too early to tell whether the adult and adolescent booster shots will curb the spread of pertussis because it can take years for a significant number to get shots.

While no vaccine is 100 percent effective, some parents are surprised and angry that a vaccine they trusted is failing to protect some children. And officials with the Georgia Division of Public Health said too many local doctors are not aware the disease is circulating in the community and can infect fully vaccinated children.

Earlier this month, the state health department sent a blast fax to area pediatricians and family doctors alerting them to be on the lookout for pertussis.

East Cobb parent Laurie Wood assumed her children were protected because they’d received all the shots. Then her 8-year-old son, Charlie, developed a cough so severe it caused him to vomit. In January, Charlie was diagnosed with pertussis.

“I was scared because he’s been vaccinated,” Wood said last week. “I also was mad because if the vaccination wasn’t working, we should have known about it.”

So far this year, 48 pertussis cases have been reported in Georgia, continuing an uptick in reports to state health officials that began last year when 103 cases were reported. Five Georgia infants have died from whooping cough since 2004.

Whooping cough starts with coldlike symptoms, but after a week or two, a severe cough can develop. Children can cough violently until all the air in their lungs is gone and they inhale with a “whooping” sound.

Between August and February, 18 cases were reported at four elementary schools in the Cobb County School District, including two third-graders at Mountain View; two second-graders and two fourth-graders at Garrison Mill; and three first-graders at Timber Ridge. Nine children had the disease at Rocky Mount Elementary: three third-graders, three fourth-graders and three fifth-graders.

Wood’s son Charlie is a third-grader at Kincaid Elementary — just a few miles from Mountain View.

It was somewhat surprising that so many of the cases involved young children who were fully vaccinated, said Stacey Martin, a CDC epidemiologist who was involved in investigating the cluster.

Nationally, school-age children diagnosed with the disease are generally teenagers, which is what prompted a CDC advisory panel in 2005 to recommend an additional pertussis booster shot at age 11 or 12.

To try to determine the magnitude of the problem at the four Cobb schools, last month CDC and local health officials gave voluntary pertussis tests to 108 children and staff who were currently coughing, and 22 of them showed evidence of recent infection, said Julie Gabel, a state health department epidemiologist.

Despite the study’s test results, some doctors refused to believe parents when they said that their children had pertussis. “More than one said to the parent: ‘Well, your child couldn’t have had pertussis, your child’s been vaccinated,” Gabel said, adding that the department is working to educate physicians.

At the four schools, health officials think the outbreaks are over or winding down. But whooping cough continues to be reported elsewhere. Georgia health officials aren’t aware of any other current whooping cough clusters.

Dr. Walter Orenstein, a leading vaccine expert, was surprised to hear that the Cobb cluster involved young students who would have received a pertussis booster as they entered school.

“The real issue is what the rate of vaccine failure is,” said Orenstein, a former CDC official who recently became deputy director for vaccine preventable diseases at the Gates Foundation in Seattle.

It’s possible, Orenstein said, that the sick children were simply among the expected 15 percent of people immunized that the vaccine fails to protect.

Despite concerns about pertussis, the reported cases are still far fewer than before a vaccine became available.

In the 1920s and 1930s, there were more than 160,000 cases and more than 5,000 deaths each year. After the introduction of a pertussis vaccine in the 1940s, reports dropped dramatically. In 1976, just 1,010 cases were reported — the record low.

Whether it’s possible to develop a more effective pertussis vaccine is a matter of scientific debate. But Dr. John Robbins, a scientist at the National Institutes of Health, has urged in scientific journals that a more effective vaccine be made using a different way of creating the component that produces immunity.

“I think we’d probably get rid of the disease,” Robbins said.

Vaccine manufacturers aren’t looking for more effective vaccine because the current one is “good enough” — especially once more adolescents and adults start getting booster shots, said Dr. Michael Decker, a vice president at Sanofi Pasteur. His company and GlaxoSmithKline make pertussis vaccines.

Decker said there’s nothing unusual about the Cobb cluster. Until the U.S. population is more thoroughly vaccinated and receiving booster shots, he said, such clusters will occasionally occur across the country. “I look at this and see absolutely nothing remarkable,” he said.



Despite concerns about pertussis, the reported cases are still far fewer than before a vaccine became available.

In the 1920s and 1930s, there were more than 160,000 cases and more than 5,000 deaths each year. In the 1940s, after the introduction of a pertussis vaccine, reports dropped by more than 99 percent. In 1976 just 1,010 cases were reported — the record low.


2009* 48

2008 103

2007 37

2006 102

2005 78

2004 71

2003 n/a


2009* 1,699

2008 10,007

2007 10,454

2006 15,631

2005 25,617

2004 25,827

2003 11,647

* Year so far

Source: CDC and Georgia Division of Public Health



What is whooping cough?

A contagious disease caused by bacteria called Bordetella pertussis.

What are the symptoms?

At first: runny nose, congestion, sneezing, and perhaps a mild cough or fever. After one or two weeks, a severe cough begins that can be so violent and repeated that children are forced to inhale with a loud “whooping” sound.

Who’s at risk?

Infants and very young children develop the most severe illness. More than half of infants younger than 1 must be hospitalized.

How is it spread?

Coughing and sneezing while in close contact with other people.

How is it prevented?

Vaccination. Children: Five shots of DTaP vaccine (which protects against diphtheria, tetanus and pertussis): Given at 2, 4 and 6 months of age; the fourth shot is given when the child is between 15 and 18 months old; the fifth shot is given when the child enters school, around 4-6 years old. Pre-teens: One booster shot — called a Tdap — during their regular check-up when they’re 11 or 12 years old. Tdap protects against tetanus, diphtheria and pertussis. Adults: Adults also should get one Tdap shot, to increase their pertussis immunity if they didn’t get one when they were a pre-teen.

Edited 7/28/2009 2:04 pm ET by crunchymomto2