Refusal to Consent to Vaccination Bay County Juvenile Home

The Bay County Juvenile Home as a Child Caring Institution is required to offer immunizations to youth every 30 days. The Bay County Health Department will provide immunizations to the youth at the Bay County Juvenile Home every first Thursday of the month unless scheduled otherwise. BCJH staff shall use this document when a parent or youth refuses any recommended vaccine. Place this completed form in the youth's file and provide to the Health Department Nurse who presents for the immunization clinic.

The Bay County Juvenile Home and/or The Bay County Health Department have advised me that my child (named above) should receive the following vaccines:

 

Diphtheria, tetanus, acellular pertussis (DTaP) Diphtheria, tetanu

nt have advised me that my child (named above) should receive the following vaccines:s (DT or Td) Haemophilus influenzae type B (Hib) Hepatitis A (Hep A) Hepatitis B (Hep B) Human papillomavirus (HPV) Influenza Measles, mumps, rubella (MMR) Meningococcal (MCV or MPSV) Pneumococcal vaccine (PCV or PPSV) Polio (IPV) Rotavirus (RV) Tetanus, diphtheria, acellular pertussis (Tdap) Varicella (chickenpox) (Var) Other:

 

I have been given the opportunity to read the Centers for Disease Control and Prevention’s Vaccine Information Statement(s) explaining the vaccine(s) and the disease(s) they prevent (BCJH staff have the information available upon request or contact the Bay County Health Department 989(895-4009 option #2).  I understand the following:

• The purpose of the recommended vaccination
• The risks and benefits of the recommended vaccination
• Possible consequence(s) of not allowing my child to receive the recommended vaccination may include contracting the illness the vaccine is intended to prevent and transmitting the disease to others
• The Bay County Health Department, the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the Michigan Department of Health and Human Services strongly recommend that the vaccine(s) be given.

I understand I may contact the The Bay County Health Department Immunization Clinic (989)895-4009 option #2 with any questions

I know that I may change my mind and accept vaccinations for my child in the future by contacting the Bay County Juvenile Home or the Bay County Health Department and completing the consent forms.

I accept sole responsibility for any consequences as a result of my child not being vaccinated. I acknowledge that I have read this document in its entirety and fully understand it.

Please note that this document is not a waiver form. A waiver form is a document that can be signed when you are exempting from vaccines that are required for school and childcare. Please see www.michigan.gov/immunize for more information on waiver