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UW Health Ambulatory Childhood Vaccine Refusal (3.1.1)

UW Health Ambulatory Childhood Vaccine Refusal (3.1.1) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Consent


Policy Title: UW Health Ambulatory Childhood Vaccine Refusal
Policy Number: 3.1.1
Category: UW Health
Type:. Ambulatory
Effective Date: August 7, 2015


To provide a process for documenting parental or guardian decline or deferral of the Advisory Committee on
Immunization Practices (ACIP) recommended childhood vaccines for patients aged from birth to 18 years.


All staff w ill promote and support the routine use of safe and effective immunizations, as defined in the
Recommended Immunization Schedules for Persons Aged 0 up to the child’s 18th birthday, as
recommended by the ACIP, w hich is comprised of representatives from the Centers for Disease Control and
Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Academy of Family
Physicians (AAFP).

The UW Health Immunization Task Force discourages any practice that deviates from the ACIP Routine
Immunization Recommendations.

Healthcare providers should anticipate that certain parents/guardians or patients w ill question the need for or
safety of vaccination, refuse certain vaccines, or even reject all vaccinations. A limited number of persons
w ill have religious or personal objections to vaccinations. For patients and parents /guardians w ho refuse
immunizations, refusal forms should be used. Parents/guardians should be counseled by a healthcare
provider on the risks of declining to follow recommendations. Parents/guardians should be advised of state
law s pertaining to school or child-care entry, w hich might require that unvaccinated children be excluded
from school or child care during outbreaks.

For providers w ho choose to offer alternative immunization schedules, a vaccine refusal form should be
completed, indicating that they have been counseled on the recommended schedule and declined to follow
those recommendations.

Immunization status should be assessed at every pediatric visit in clinics w here vaccines are offered, but
documentation of refusal/deferral is required annually. Readdress the need for completion of a new refusal
form w ith each new vaccine recommended (includes seasonal vaccines) based on the ACIP Routine
Immunization Schedule.

A. The clinic staff w ill provide the appropriate Vaccine Information Statement(s) (VIS) from the CDC and give
the parent/guardian an opportunity to read, ask questions about, and discuss the information w ith the
provider in the patient’s preferred language.
B. When a parent/guardian refuses or defers an immunization, clinic staff w ill verify a Vaccine Refusal Form
has been completed and signed w ithin the last year, if not, it w ill need to be completed. Note: Providers w ill
need to respond to a parent/guardian w ho refuses one or more immunizations and also refuses to sign the
refusal form on an individual basis by documentation in the medical record
C. A health care provider or clinical staff member w ill w itness and date the form; offering a copy of the signed
form to the parent/guardian.
D. The health care provider that provided counseling should sign and date the form prior to scanning, if the
provider is also the w itness to the parent signature, only one signature is required.
E. The original form w ill be scanned into the patient’s medical record and can be found under the media tab in
chart review .
F. Document refusal in Health Link:
1. A Smart Set may be used to assist in documentation. From the Immunization Refusal Smart Set:
check the SmartText Vaccine Refusal Documentation.
2. Add appropriate vaccine refusal diagnosis to patient’s problem list.
3. The provider should use the ‘diagnosis code’ appropriate for the specif ic patient situation (provided
in SmartSet).

Policy Title: UW Health Ambulatory Childhood Vaccine Refusal
Policy Number: 3.1.1

G. The refusal should be entered into Wisconsin Immunization Registry (WIR), by the clinic staff, under client
comments, noting the vaccine refused and the date of refusal.

UW Health Pediatric Vaccine Refusal Form


Author(s): Director, Center for Clinical Know ledge Management (CCKM)
Senior Management Sponsor: VP, Quality and Patient Safety
Approval committees: Immunization Task Force; Primary Care Leadership Committee; Antimicrobial Use
Subcommittee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 15, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter New comer, MD
Chief Medical Officer for UW Health

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

Version: Revision
Next Revision Due: August 7, 2018
Formerly Know n as: Hospital Administrative policy #8.96 and UWMF UW Health Ambulatory Childhood
Vaccine Refusal