Edit, Download, and Sign the Refusal to Vaccinate Form - Georgia Department of Public Health
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How do I fill this out?
To fill out this form, start by providing the necessary client information at the top. Next, check the boxes next to the recommended vaccines you or your child are declining. Finally, sign and date the form to acknowledge your understanding of the implications of refusing vaccination.
How to fill out the Refusal to Vaccinate Form - Georgia Department of Public Health?
1
Read the instructions carefully.
2
Fill in the client and guardian information.
3
Select the vaccines you are refusing.
4
Review the form to ensure accuracy.
5
Sign and date the form at the end.
Who needs the Refusal to Vaccinate Form - Georgia Department of Public Health?
1
Parents or guardians of children who are unvaccinated.
2
Individuals seeking to opt-out of required vaccinations.
3
Healthcare providers needing to document vaccine refusals.
4
Schools requiring documentation for immunization records.
5
Childcare facilities needing proof of vaccination status.
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What are the important dates for this form in 2024 and 2025?
The Refusal to Vaccinate form should be submitted before the start of each school year or prior to daycare enrollment. Check with your local health department for any changes in requirements for 2024 and 2025.
What is the purpose of this form?
This form serves as a formal notice to refuse vaccinations for individuals. It outlines the necessary information regarding vaccines, their benefits, and potential risks of refusal. Understanding the implications of declining immunization is crucial for informed decision-making.
Tell me about this form and its components and fields line-by-line.
- 1. Client Name: The full name of the individual refusing vaccination.
- 2. Client DOB: Date of birth of the client.
- 3. Parent/Guardian Name: Name of the parent or guardian filling out the form.
- 4. Healthcare Provider's Name: Name of the healthcare provider offering vaccination.
- 5. Healthcare Provider's Address & Phone: Contact information of the healthcare provider.
- 6. Vaccines Declined: List of vaccines the client has chosen to refuse.
- 7. Client/Parent/Guardian Signature: Signature of the person filling out the form.
- 8. Date: Date the form is filled out.
What happens if I fail to submit this form?
Failure to submit this form may result in unvaccinated children being denied access to schools or childcare facilities. Important health documentation will be missing from medical records, potentially resulting in health risks.
- Risk of Disease: Unvaccinated children are at a heightened risk of contracting preventable diseases.
- Exclusion from Educational Settings: Without proper vaccination documentation, children may be barred from attending school or daycare.
- Impact on Public Health: Lower vaccination rates can lead to outbreaks of vaccine-preventable diseases.
How do I know when to use this form?
- 1. Informed Refusal: The form is used to ensure that the parent or guardian has understood the implications of refusing vaccines.
- 2. School Enrollment: Required for enrolling children in schools that mandate vaccination records.
- 3. Childcare Facility Requirements: Necessary documentation for attending daycare or childcare programs.
Frequently Asked Questions
What is the purpose of the Refusal to Vaccinate form?
The form allows parents or guardians to formally decline vaccinations for children while acknowledging the risks.
How can I fill out the form?
Use PrintFriendly's PDF editor to enter your details and select the vaccines you are declining.
Can I save the edits I make to this form?
You can download the edited version of the form, ensuring your changes are retained.
What happens after I submit the form?
Your healthcare provider will receive the form to document your refusal of vaccinations.
Is there a specific format for this form?
The form follows a standard layout required by the Georgia Department of Public Health.
Do I need to provide my signature?
Yes, a signature is required to indicate your acknowledgment of the risks involved.
How can I share the finished document?
You can share it via email or create a link using the sharing features in PrintFriendly.
What should I do if I change my mind about vaccination?
You can discuss this with your healthcare provider and submit a new form if necessary.
Who reviews this form once submitted?
Typically, your healthcare provider will review and retain this document in your medical records.
Are there any penalties for refusing vaccination?
While there are no penalties for individual choices, unvaccinated children may be excluded from school.
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