VACCINE WAIVER FORM
CHAPTER 333 HEALTH
PUBLIC HEALTH CODE
ARTICLE 9. SUPPORTIVE PERSONAL HEALTH SERVICES
PART 92. IMMUNIZATION
§ 333.9215. Exemption of child; immunization detrimental to health or not appropriate, physician certificate; religious convictions or other objections, parent's written statement.
Sec. 9215. (1) A child is exempt from the requirements of this part as to a specific immunization for any period of time as to which a physician certifies that a specific immunization is or may be detrimental to the child's health or is not appropriate. (2) A child is exempt from this part if a parent, guardian, or person in loco parentis of the child presents a written statement to the administrator of the child's school or operator of the group program to the effect that the requirements of this part cannot be met because of religious convictions or other objection to immunization.
Patient Name_______________________________ Birthdate_______________
As the parent/guardian of __________________________, I have investigated the risks and benefits of the following vaccines and diseases. I am aware that there are documented cases of people contracting diseases for which they are clinically fully immunized and that the manufacturers of the vaccines do not guarantee 100% efficacy. I am also aware that VAERS (Vaccine Adverse Events Reporting System) documented cases of over 54,000 adverse reactions from vaccines in a 20-month period. The National Vaccine Injury Fund, created in 1986 to compensate those damaged by vaccines has paid out over one billion dollars in compensation to date.
I have researched both the risks of not vaccinating, and the disease statistics occuring in the US (http://www.cdc.gov/mmwr/mmwr_wk.html), and I believe that the chances of my child having an adverse reaction are much higher than his chances of contracting one of these diseases.
POLIO: I understand that there have been no cases of wild polio in the US in the last 20 years and that those cases which have been documented have been caused by the vaccine. I understand the following side effects for the vaccine are possible:
Killed virus polio: temperature of *102 in up to 38%, sleepiness, fussiness, crying, decreased appetite, vomiting, Guillain-Barré Syndrome and allergic reaction in those allergic to neomycin, polymyxin B and streptomycin.
HEMOPHILUS INFLUENZAE B: I have been informed of the risk of my child developing meningitis (although this vaccine will not protect the child from meningitis from all other forms such as pneumococcus, and meningococcus, viruses, and fungi). Incidence of this disease today is low and the vaccine has not proven to be highly effective in 41% of cases, according to some studies. Reactions include: contracting HIB, localized pain, erythema and induration, fever >100.6 , irritability, lethargy, anorexia, rhinorrhea, diarrhea, vomiting, cough, when administered alone. Reactions occurred in up to 30% of patients. When administered in conjunction with the DPT, reactions include local tenderness erythema and induration, fever >100.8 , irritability, drowsiness, anorexia, diarrhea, vomiting, persistent crying, seizures, urticaria, hives, renal failure, Guillain-Barré Syndrome and death. Reactions occurred in up to 77.9% of patients.(
PERTUSSIS: I have been informed of the risk of my child developing whooping cough. I understand the disease is rarely fatal, with a 99.8% recovery rate. It is most serious and life-threatening in children under 6 months old, but there are adequate methods of treatment available. Side effects of the DTaP were only tracked for only 72 hours and included: tenderness, erythema, induration, fever >102.2 , drowsiness, fretfulness, vomiting, upper respiratory infection, diarrhea, rash, febrile seizures, persistent or unusual crying, lethargy, hypronic-hyporesponsive episode, urticaria, anaphylactic shock, convulsions, encephalopathy, mono- and polyneuropathies and death
DIPHTHERIA: According to the CDC, there have been no documented cases of Diphtheria in the US in the last 2 years. The Diphtheria component is most often given within the DPT or DaPT and includes the same side effects and reactions as those listed for pertussis.
RUBEOLA (MEASLES: I have been informed of the risk of my child developing rubeola. There were only 37 reported cases in the US, in 2003. As of the date of this waiver, there have only been 7 reported cases of Rubeola in the US, according to the CDC (http://www.cdc.gov/mmwr/) . Some adverse reactions include: stinging or burning at the injection site, anaphylaxis, fever up to one month following injection, rash, cough, rhinitis, erythema multiforme, lymphadenopathy, urticaria, diarrhea, febrile convulsions, seizures, thrombocytopenia purpura, vasculitis, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies.
MUMPS: I have been informed of the risk of my child developing mumps. I understand that mumps is rarely harmful in childhood, and that most of the above risks occur when mumps is contracted in adolescence or adulthood.I understand that there is a Mumps vaccine which poses the following risks: contraction of mumps from the live vaccine, burning or stinging at the injection site, anaphylaxis, cough, rhinitis, fever, diarrhea, vasculitis, parotitis, orchitis, purpura, urticaria, erythema multiforme, optic neuritis, retrobulbar neuritis, syncope, encephalitis, febrile seizures, and nerve deafness.
RUBELLA (GERMAN MEASLES): I have been informed of the risk of my child devoping Rubella. According to the CDC, (http://www.cdc.gov/mmwr/) there were only 6 documented cases of Rubella in 2003, and 15 cases as of the date of this waiver, for 2004, in the US.
Adverse reactions include: contracting rubella from the live virus in the vaccine, burning or stinging at the site, lymphadenopathy, urticaria, rash, malaise, sore throat, fever, headache, dizziness, nausea, vomiting, diarrhea, polyneuritis, arthralgia, arthritis, local pain and inflammation, erythema multiforme, cough, rhinitis, vasculitis, anaphylaxis, syncope, optic neuritis, retrobulbar neuritis, papillitis, Guillain-Barré Syndrome, encephalitis, thrombocytopenia, purpura, and Chronic Fatigue Syndrome.
HEPATITIS B: I have been informed of the risk of my child developing Hepatitis B viral infection. I understand that my child's risk of developing Hepatitis B is low if I am not a carrier or infected, if my child does not engage in promiscuous sex or use drugs. According to the Academy of American Physicians and Surgeons, children ages 13 and under are 3 times as likely to have an adverse reaction, including death, then they are to contract Hep B.
VARICELLA (CHICKENPOX: I have been informed of the risk of my child developing chicken pox . I understand chicken pox is generally benign in children, but results in significant lost hours at work for parents. Side effects and adverse reactions for the chicken pox vaccine include: contracting chicken pox from the live vaccine (27%), pain and redness at site, swelling, erythema, rash, pruritus, hematoma, induration, stiffness, upper respiratory illness, cough, irritability/nervousness, fatigue, disturbed sleep, diarrhea, loss of appetite, vomiting, otitis, diaper rash/contact rash, nausea, eye complaints, chills, lymphadenopathy, myalgia, lower respiratory illness, headache, teething, malaise, abdominal pain, other rash, allergic reactions including rash and hives, stiff neck, heat rash/prickly heat, arthralgia, eczema/dry skin/dermatitis, constipation, itching, pneunonitis, febrile seizures, and cold/canker sore. Varicella vaccine is cultured on cells from aborted babies, and guinea pig cell cultures.
Tetanus: I have been informed of the risks of Tetanus. According to the CDC (http://www.cdc.gov/mmwr/), there were only 9 documented cases in the US in 2003. amd only 7 documented cases in the US for 2004, as of the date of this waiver.