An example of refusal of consent to vaccination. Application

Voluntary informed consent to preventive vaccinations for children or refusal of them

1. I, the undersigned__________________________________________ _________________________________________________________________________ (last name, first name, patronymic of the parent (other legal representative) of a minor under the age of 15, a minor with drug addiction under the age of 16)/a minor over the age of 15, a minor with drug addiction in age over 16 years) __________________________________________________________ year of birth, (indicate the year of birth of a minor over the age of 15 years, a minor with drug addiction over the age of 16 years) I hereby confirm that I have been informed by a doctor: a) that preventive vaccination is introduction of a medical immunobiological preparation into the human body to create specific immunity to infectious diseases; b) about the need for preventive vaccination, possible post-vaccination complications, and the consequences of refusing it; c) on medical care during preventive vaccinations, including a mandatory medical examination of a minor under the age of 18 before vaccination (and, if necessary, a medical examination), which is included in the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation and is provided in state and municipal health care institutions free of charge; d) on compliance with the instructions of medical workers. 2. I am informed that in accordance with paragraph 2 of Article 5 of the Federal Law of September 17, 1998 N 157-FZ “On Immunoprophylaxis of Infectious Diseases”*(1) the absence of preventive vaccinations entails: a ban for citizens to travel to countries where, in accordance with international health regulations or international treaties of the Russian Federation, stay in which requires specific preventive vaccinations; temporary refusal to admit citizens to educational and health institutions in the event of widespread infectious diseases or the threat of epidemics; refusal to hire citizens for work or removal of citizens from work, the performance of which is associated with a high risk of contracting infectious diseases (Resolution of the Government of the Russian Federation of July 15, 1999 N 825 “On approval of the list of works, the performance of which is associated with a high risk of contracting infectious diseases and requires mandatory preventive vaccinations”*(2)). I had the opportunity to ask any questions and received comprehensive answers to all questions. Having received full information about the need for preventive vaccination _______________________________________________, (name of vaccination), possible vaccination reactions and post-vaccination complications, the consequences of refusing it, I confirm that I understand the meaning of all terms, and: voluntarily agree to undergo vaccination *(3) _________________________________________________________________________ (name vaccinations) (I voluntarily refuse to vaccinate _________________________________________________________________________, (name of vaccination) to a minor _____________________________________________________ ________________________________________________________________________. (indicate the surname, first name, patronymic and year of birth of a minor under the age of 15 years/a minor with drug addiction under the age of 16 years) I, the undersigned) *(4) _____________________________________ ________________________________________________________________________________ (last name, first name, patronymic of the parent (other legal representative) of a minor under the age of 15, a minor with drug addiction under the age of 16)/a minor over the age of 15, a minor with drug addiction over the age of 16 ) Date ___________________ ______________________ (signature) I certify that I have explained all issues related to the administration of preventive vaccinations to a minor and provided answers to all questions. Doctor ________________________ ___________ Date _______________ (last name, first name, patronymic) (signature)

Although the schedule of preventive vaccinations provides for mandatory vaccination against a number of diseases, you can refuse it. Doctors do not recommend making such a decision without compelling reasons. When registering a child at a children's clinic, a number of documents are filled out.

One of the first and most important is voluntary informed consent to preventive vaccinations for children or refusal of them. A sample of such documentation was approved by order of the Ministry of Health of the Russian Federation on January 26, 2009 under number 19n. Filling out the form allows you to agree or refuse routine vaccination.

The document is needed in order to:

confirm the parents' consent to the child's vaccination;
provide the opportunity to legally refuse vaccinations;
confirm that the mother (father, guardian) is informed of all the risks associated with refusing immunization;
remove responsibility from doctors for parents’ refusal to vaccinate their baby.

Consent (refusal) from vaccination is pasted into the child’s card.

The document is valid until the age of 18. Before each prevention of bacterial and viral pathologies, parents are informed about what drug, from what and when the baby will be immunized.

Despite the completed voluntary informed consent form, before each vaccination, the child’s representative is additionally required to confirm approval for the manipulation in writing.

How to correctly fill out a vaccination consent form for school?

Voluntary informed consent is drawn up according to form No. 13849, approved by the Ministry of Health on April 28, 2009. To write such a document, the clinic is required to issue a form and provide a sample to fill out.

Before entering information into the vaccination consent document for school, you need to decide which vaccinations your child will receive: all according to plan or some separate ones. Before drawing up the document, the doctor is obliged to inform about all vaccines, the importance of their use and the risks of refusing them. If you have any questions, you should ask your doctor.

The following people have the right to fill out a vaccination consent form for school:

parents of the baby;
guardians;
adoptive parents.

Rules for filling out the consent form for vaccination:

do not make blots, cross-outs, or corrections. You cannot use a corrector;
Before filling out, carefully read the text of the form;
in the first paragraph, indicate the full name of the person filling out the document;
cHow to correctly write voluntary informed consent for preventive vaccinations? The form, first of all, should not contain errors or corrections. Secondly, the name of the vaccination, the baby’s full name, and his date of birth. Also here you need to emphasize the word “I agree”;
at the end put the date of completion and signature;
in the last line the doctor must indicate his data (full name) and sign;
it is recommended to make a note on the form that each time before administering the vaccine to a child, the consent of his representative to carry out the manipulation is required;
The document should be drawn up in two copies: the first version remains within the walls of the clinic, the second is given to the patient.

It happens that a medical institution does not issue a special form. In this case, you can write a statement.

The application contains the following information:

passport details of the child’s representative;
laws governing immunization;
name of the vaccine;
child’s details (date of birth, full name);
consent to vaccination;
awareness;
date of document preparation, signature.

How to correctly write a refusal to vaccinate?

Today, more and more parents are deciding to refuse vaccination. The main reason for this is the stories on Internet forums that the vaccination has led to a number of serious consequences. Many have lost confidence in domestic medicine. Not everyone has enough money to carry out immunization.

The refusal must be issued in writing. The doctor is obliged to inform about all the consequences that may await an unvaccinated child. Parents must make decisions carefully. In this case, all responsibility for the baby’s health falls on his representative.

It is important to be able to correctly write a refusal to vaccinate. There are special forms in which you just need to fill out a few lines and add a dated signature. It happens that you have to fill out an application by hand.

Rules for writing a waiver of immunoprophylaxis:

It is mandatory to indicate the personal data of the compiler and the child (full name, date of birth, residential address);
note which vaccinations you want to refuse and for how long;
indicate awareness of the consequences of refusal, thoughtfulness of the decision made;
provide references to Federal Laws of the Russian Federation No. 157, 77 indicating articles and parts;
Before filling out the form, you must study it carefully;
do not make mistakes, do not make corrections. Crossing out or painting over information by a proofreader makes the document invalid;
At the end, be sure to put the date of compilation and signature;
The refusal should be written in two versions. The first copy is kept in the medical institution, and the second copy is kept by the baby’s representative.

A refusal can be written for any period until the child reaches adulthood. If the decision changes, the document can be reissued.

How to write a letter of refusal to receive a flu vaccination?

Answers:

Personal Account Removed

Something like this: To the director of the municipal educational institution secondary school No. Full name Parent of the student — class Full name Application. I, Full Name, declare my refusal to get vaccinated against influenza for my child Full Name, studying at Municipal Educational Institution Secondary School No., on the basis of: 1. Fundamentals of the legislation of the Russian Federation on the protection of public health dated July 22, 1993 No. 5487-1, Article 32 (Consent to medical intervention) and 33 (Refusal of medical intervention); 2. Federal Law of September 17, 1998 No. 157-FZ “On Immunoprophylaxis of Infectious Diseases”, Article 5 (Rights and Responsibilities of Citizens in the Implementation of Immunoprophylaxis) and Article 11 (On Vaccination with the Consent of the Parents of Minors) “——” month year . Signature

irina

I am Natalya Dubetskaya. I refuse the flu shot for my daughter (name). signature number

Mouse Norushka

Ask your daughter, was she not given a standard form at school? Before each vaccination, my son was given this form in elementary school, the general meaning is - can I get vaccinated or not? No vaccinations were given without a form filled out by the parents until clarification with the parents.

Can a child be vaccinated without parental permission?

If the child is a minor, then they have no right to vaccinate him without the permission of his parents. A person over 18 years of age can independently agree to immunoprophylaxis. Until this age is reached, parents or guardians are responsible for it.

Today, it is not uncommon for children to be vaccinated without the knowledge or consent of their representatives. This contradicts Federal Law No. 157 “On the immunoprophylaxis of infectious diseases.”

Article 11 of the current document states that all vaccinations are carried out only with the informed voluntary consent of the child’s legal representatives to such medical intervention. If a minor was vaccinated without the approval of the parents or with a written refusal of the manipulation, then you need to write a complaint addressed to the head of the medical institution.

The clinic is obliged to compensate for moral and physical damage. If contacting the manager does not give any result, then you should file an application with the prosecutor's office. It is also worth sending copies of the application to the regional department of health or education.

A medical institution that immunized a minor child without parental consent will face the following consequences:

higher authorities will oblige you to compensate for damages in a certain amount of money. Compensation is carried out only on the basis of a court decision;
the culprit (pediatrician, nurse) will be subject to disciplinary or administrative liability. If the vaccination caused great harm to health, led to disability or, then the violator will be punished under the Criminal Code.

Judicial practice related to post-vaccination complications

The driving force behind the anti-vaccination movement is post-vaccination reactions and complications. It is the psychology of their perception, or rather, its anomalies among traffic participants, that become the subject of litigation and litigation. Conventionally, all judicial practice in such cases can be divided into two groups:

Real cases of post-vaccination reactions and complications (decision of the Industrial District Court of Stavropol dated November 17, 2010 in case No. 2-3050/2010; Resolution of the Volgograd Regional Court No. 44G-98/2019 4G-1286/2019 dated March 29, 2021 on case No. 2-16/2018; decision of the Megion City Court of the Khanty-Mansiysk Autonomous Okrug - Ugra dated June 27, 2021 in case No. 2-453/2018), caused by violations by employees of medical organizations of the requirements for preventive vaccinations against infectious diseases. In 2018, the court recovered 1,200,000 rubles from doctors in favor of the parents of a 3-month-old boy, who was vaccinated (against polio and DPT) in violation of the requirements and contrary to a medical exemption (the boy had a primary immunodeficiency state - clause 2 of the List medical contraindications to preventive vaccinations, approved by the Chief State Sanitary Doctor of the Russian Federation, First Deputy Minister of Health of the Russian Federation on January 09, 2002).
According to the child’s mother, approximately 4 days after vaccination, her son developed loose stools, a fever, and completely immobilized his limbs. The boy was hospitalized with a diagnosis of “acute viral myelitis, flaccid tetraparesis with moderate motor impairments in the arms, severe motor impairments in the legs.” The child was in hospital for four months, including preventive treatment, after which the final diagnosis was established: “a polyviral infection caused by type 3 vaccine virus in a recipient of oral polio vaccine, widespread spinal form, lower paraparesis,” and the child was recognized as disabled.
A forensic medical examination carried out during the consideration of the claim confirmed the existence of a cause-and-effect relationship between the actions of doctors and the deterioration of the child’s condition: vaccination was carried out in violation of clause 9.1 SP 3.1.2951-11 “Prevention of Poliomyelitis”, Order of the Ministry of Health of the Russian Federation dated March 21, 2014 No. 125n, where it is stated that the first vaccination against polio is carried out with a vaccine for the prevention of polio (inactivated), and the pediatrician prescribed a live polio vaccine, which is regarded as a defect in the provision of medical care. Moreover, the boy’s general blood test showed signs of eosinophilia, which could indicate a decrease in immunity, and a slight increase in the erythrocyte sedimentation rate - one of the signs of the body’s inflammatory response. All this could contribute to a decrease in the child’s immunity and, as a result, to his illness with polio as a result of vaccination, since under normal conditions the live polio vaccine does not cause such complications, but only if the patient has immunopathological conditions. The guilty medical workers were subject to disciplinary action.
In the Tyumen region, the court ordered to pay 800,000 rubles to the mother of a child who, a year and a half after birth, became disabled due to a vaccination that he should not have received (decision of the Ishim City Court of the Tyumen region dated February 20, 2014 in case No. 33-2200/2014 ).
The claim was filed by the mother of a baby who was vaccinated against tuberculosis on the third day after birth. A year later, the parents discovered that the boy stopped leaning on his right leg when trying to walk. Examinations showed that he had tuberculous right-sided coxitis of the hip joint. In January 2011, the child was operated on, and in April of the same year he was declared disabled.
In allowing the stated demands, the court proceeded from the fact that the vaccination was carried out by the defendant in violation of Art. 32 Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens” dated July 22, 1993 and Part 1 of Art. 5 of the Federal Law “On Immunoprophylaxis of Infectious Diseases” dated September 17, 1998 No. 157-FZ. According to these standards, a necessary precondition for medical intervention is the informed voluntary consent of the citizen. The court found that the mother was not explained the possible complications when vaccinating her child. In addition, the woman had an intrauterine infection, which was a contraindication for vaccination.
Read also: Registration of consent to vaccination (refusal to vaccination): legal aspect
As you can see, if a doctor vaccinates despite existing contraindications, or does not inform parents in writing about possible adverse consequences, he is responsible for this.

Imaginary victims of vaccination who make demands to recover compensation for lawsuits from the state and medical organizations (decision of February 7, 2013 of the Karasuksky District Court of the Novosibirsk Region in case No. 2-3/2013; decision of March 3, 2014 of the Ingodinsky District Court Chita (Trans-Baikal Territory) in case No. 2-446/2014) or vaccine manufacturing companies (for example, the unsatisfied claim in the MMR scandal amounted to 14 million pounds sterling).

Thus, in the Kurgan region, the court refused to collect 700,000 rubles of moral damages from the medical organization from the mother of the child, since there was no sufficient data indicating a violation of professional standards and rules for the provision of medical care and treatment (decision of the Kurtamysh district court of the Kurgan region dated March 26, 2009 . in case No. 2-3/2009).

In support of her claims, the mother of the minor referred to a violation of the technique of BCG vaccination, which was administered to her child on the day of discharge from the maternity ward of the hospital. After 5 months, she discovered a tumor on the back of her daughter’s head, the child’s condition gradually began to deteriorate, and a series of operations followed. A diagnosis was made of tuberculous axillary lymphadenitis. As part of this case, forensic medical and commission forensic medical examinations were carried out, the conclusions of which did not establish a cause-and-effect relationship between the quality of medical care and the development of complications in the child.

The appearance of pathological processes in the form of lymphadenitis in children in the post-vaccination period does not in itself mean the presence of a direct causal relationship between vaccination and the development of pathological processes, because the latter can arise as a result of the provoking effect of vaccinations, during exacerbation of chronic diseases, “revival” of a latent infection, or in the presence of a concomitant infection, which can change and aggravate the body’s response to vaccination. The absence of characteristic complications and their consequences in the form of a “cold abscess” (dense infiltrate at the site of vaccine administration, as a result of subcutaneous administration), or a keloid scar at the site of vaccine administration indicates compliance with professional vaccination standards. The examination did not establish any violations during vaccination, and the diagnosis “tuberculous axillary lymphadenitis on the left” made at the medical institution does not have sufficient objective justification.

Thus, the court came to the conclusion that the senior midwife of the maternity ward of the Kurtamysh Central District Hospital did not violate the vaccination technique when inoculating with the BCG vaccine, and also that the only reason for the complication in the child in the form of tuberculous axillary lymphadenitis on the left was not a violation of the vaccination technique (administration of the BCG vaccine under skin instead of intradermal injection), as well as there is no evidence that there were other actions of the medical staff of the Central District Hospital that were causally related to the disease the child received.

In 2021, the Ramensky District Court of the Moscow Region denied the child’s mother compensation for moral damages in the amount of 3,000,000 rubles (decision of the Ramensky City Court of the Moscow Region dated April 5, 2021 in case No. 2-5823/2017). In support of the requirements, the child’s mother indicated that her son, at the age of 6 months, was diagnosed with the consequences of vaccine-associated poliomelitis, flaccid paresis of the right lower limb. The child has been disabled since childhood and is deprived of the ability to move independently. She believed that the child’s illness was in a direct cause-and-effect relationship with the polio vaccination given to him by doctors at the Bronnitsy City Hospital in 2004.

During the trial, a forensic medical examination was carried out, according to the conclusion of which it was established that before the vaccination there were no objective or subjective reasons for medical withdrawal, no defects in the provision of medical services were identified, and there was a cause-and-effect relationship between the polio vaccination and the complications that arose in the child were not established.

Moreover, the expert commission, on the basis of the presented medical documentation, established that the post-vaccination consequences that developed in the child in the form of flaccid paresis of the right lower limb with its shortening were the result of the parents’ voluntary refusal of the proposed treatment and timely hospitalization of the child, self-medication of the child and failure to comply through the fault of the parents themselves in the subsequent period, all procedures prescribed to the child in full.

Thus, fueled and multiplied by numerous anti-vaccination myths, parents’ fears lead to unfounded lawsuits and the desire to punish with rubles medical organizations that “harass the health of children for the sake of profit.”

Adult consent template for immunization

Many parents do not know how to obtain consent for their child to be immunized. Especially many questions arise if the form is missing. Therefore, it is better to use established templates. You can find them on the Internet. But it is preferable to ask for a sample document writing from the medical institution to which such paper is submitted.

A template for obtaining consent from an adult for immunization is given below.

To the director of school No. 5

Vasilenko A.P.

Parents of Selivanova V.M. student of grade 1-A Selivanova E.A.

I, Valentina Mikhailovna Selivanova, agree to this, and my child, Elena Alexandrovna Selivanova. I received information about the vaccination. I am familiar with its consequences and features of the course of the post-vaccination period.

(signature)

Video on the topic

An allergist-immunologist of the highest category on whether parental consent is required for vaccination:

Thus, before each immunoprophylaxis of a minor child, doctors are required to obtain the written consent of his representatives. Without the permission of parents (guardians), carrying out any manipulations is prohibited and punishable by law.

Any mother should know that vaccinations for her child are voluntary. Before each vaccination, parents write a voluntary consent or refusal of vaccinations. In our article you will learn what kind of document this is and how to write consent and refusal of vaccinations in different institutions.

Recently, the law in the Russian Federation has established that immunization of children and adults against various infectious diseases occurs only on a voluntary basis. This means you can refuse to vaccinate your child at any time. So, already in the maternity hospital you can write an application to refuse vaccinations and get them later.

Some parents decide not to vaccinate their baby at all. In this case, the unvaccinated child is sent to kindergarten without immunity to infectious diseases. At the same time, some diseases for which vaccination is carried out can be severe and cause complications. Vaccination creates lasting immunity to the disease. Even if a child gets sick, the disease will be mild. Therefore, vaccination is a way to protect your child from many diseases in kindergarten, school and after it.

Vaccination forms immunity for a while, after which revaccination is carried out. Every time before vaccination, parents or legal representatives of the child write consent or refusal of vaccinations at the clinic, kindergarten and school. Only with such a document can medical staff administer the vaccine. If you refuse, you take responsibility for the child’s health. The application should state that you understand your responsibility and have no complaints against the medical staff.

The form for refusing vaccinations at school, as well as consent to vaccinations, can be free. You should indicate your full name, full name. child, consent or refusal of vaccinations (indicate which ones), signature with transcript and date. Consent or refusal should be written in two copies: one to give to the head of the institution, and the other to keep. When accepting an application, it must be registered in a journal with a number assigned, stamped, number, position, full name. and signature.

In clinics, parents are given a special form for voluntary consent or refusal of vaccinations. It contains basic information about vaccination: the law allowing refusal of vaccinations, and the possible consequences of refusal. This form is filled out immediately before vaccination and pasted into the child’s card. Here is an example of forms on the basis of which you can write your consent or refusal to be vaccinated.

Vaccination by law

In accordance with the current legislation of the Russian Federation, all medical procedures on a young child, including any type of vaccination, are carried out only with the written permission of one of the parents or legal representatives. Any patient has the right to refuse intervention. Otherwise, the doctor or other medical professional may be held liable.

All rules regarding the rights of the patient and employees of healthcare institutions are regulated by current regulations, including:

In case of refusal to undergo vaccination, the patient signs a corresponding statement, which has legal force. And if he gives written voluntary consent, then, in accordance with the letter of the law, it is attached to the medical record as evidence of the legality of the doctors’ actions.

In Russia, failure to vaccinate a child is not grounds for refusal of admission to school or kindergarten. Doctors classify such children as a risk group, so during epidemics they are excluded from attending educational or preschool institutions. In addition, unvaccinated citizens, including children, may be prohibited from entering some countries.

Source of the article: https://go2school.ru/dokumenty/kak-zapolnit-informirovannoe-dobrovolnoe-soglasie-na-vaktsinatsiyu

Consent/refusal to influenza vaccination

Flu vaccination is carried out in children's institutions every fall. As with other vaccinations, this will require permission from the child’s parents or legal representatives. The consent form for the flu shot, as well as the refusal form, can be free (see above what should be indicated in the application) or will be given to you at the institution on a form. If you write a refusal, do not forget to make two copies of it and make sure that the educational institution accepts it correctly.

How to write a refusal to get a flu shot, correctly adding the reasons for the refusal:

How to write consent for a flu shot: You can use the consent form above and write in the appropriate box that you agree to receive a flu shot.

Vaccination refusal form download

Dear parents, in conclusion, I would like to say that the example of the legal norms given in this article shows that the current legislation contains sufficient legal mechanisms to protect you and your children from illegal actions of medical workers
. As in everything else, in this matter it is necessary to exercise common sense, not be afraid of anything and not compromise with your own conscience. In any case, if you have questions, the best way is to communicate with like-minded people and exchange experiences, as well as consultations with competent specialists in these matters.

Elena's contacts for all parents who need advice or help, +7-921-634-55-35.

The Executive Committee is not responsible for consultations or collection of money. The phone number is provided for advertising purposes for the use of article material.