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Transcript
Anschutz Health &Wellness Center 12348 E. Montview Ave. Mail Stop H275 Aurora, CO 80045 Main: 303-724-9030 Fax: 303-724-9213 Occupational Health Program [email protected] www.ucdenver.edu/occhealth DECLINATION OF HEPATITIS B VACCINE CU DENVER/ANSCHUTZ EMPLOYEE STATEMENT I understand that due to my occupational exposure to human blood, bodily fluids or other potentially infectious materials, I may be at risk of exposure to the Hepatitis B virus (HBV) and consequently, Hepatitis B infection. I have been offered the Hepatitis B vaccine, at no charge to me. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of exposure to and infection with the Hepatitis B virus. In the future, while I continue to have occupational exposure to human blood, bodily fluids or other potentially infectious materials, if I determine I want to be vaccinated with against the Hepatitis B virus, I can receive the vaccination series at any time. _______________________________ Employee Name (printed) _______________________________ Employee Signature __________________ Date Revised 08/2014