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Modified American Academy of Pediatrics Refusal of Vaccination Form - AAP 2026

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The document is a Modified Refusal of Vaccination Form from the American Academy of Pediatrics, where parents or guardians can indicate their child's vaccination status. It lists various vaccines recommended by healthcare providers, allowing parents to mark their consent or refusal for each vaccine. The form also includes information about the risks and benefits of vaccinations, the consequences of refusing vaccines, and acknowledges that parents may change their decision regarding vaccinations in the future.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your child’s name and ID number at the top of the form. This information is essential for identifying your child’s vaccination records.
Next, fill in the parent’s or guardian’s name(s) to establish who is making the decision regarding vaccinations.
In the section listing recommended vaccines, indicate whether you agree (Y) or decline (N) for each vaccine by circling the appropriate option. Be sure to note the date for each response.
Read through the provided information about vaccine risks and benefits carefully. This section ensures you are informed about your choices.
Finally, sign and date the form at the bottom, ensuring that a witness also signs if required. This step confirms your understanding and agreement with the refusal of vaccination.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the ICD-10 code for refusal of vaccination?

ICD-10 code Z28. 21 for Immunization not carried out because of patient refusal is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What would you say to a patient that refuses to receive a vaccine?

Tell: Respond with brief but clear information centered on the patients belief or question. Watch for nonverbal reactions, and address further questions or confusion. Ask: What are your thoughts now about getting a flu shot? If the patient agrees, have your nurse administer the vaccine.

How to write a vaccine exemption letter?

I request a reasonable accommodation due to my sincere religious beliefs. I understand and assume the risks of non-vaccination. I accept full responsibility for my health, thus removing liability from the City to the required vaccinations.

What are the excuses for not getting vaccinated?

Overall, among adults aged 18 years who did not get a 202324 COVID-19 vaccine, the most commonly reported reasons for not getting one were: concern about serious/unknown side effects (39.7%), lack of concern about getting sick (33.6%), belief that the vaccine cant prevent infection (25.9%), not trusting the

How do you document parental refusal to have their children vaccinated?

Give the appropriate Vaccine Information Statement (VIS) to the parent or legal representative before each vaccine is given. This is required by federal law. When parents refuse a recommended vaccine, document that you provided the VIS(s), and have the parent sign the Record of Vaccine Declination.

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How to document vaccine refusal?

For parents who refuse one or more recommended immunizations, document your conversation, the provision of the VIS(s), and have the parent sign the vaccine refusal form and keep the form in the patients medical record.