* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download please choose one of the options below
Survey
Document related concepts
Poliomyelitis eradication wikipedia , lookup
Thiomersal controversy wikipedia , lookup
DNA vaccination wikipedia , lookup
Transmission (medicine) wikipedia , lookup
Globalization and disease wikipedia , lookup
Herd immunity wikipedia , lookup
Infection control wikipedia , lookup
Immunocontraception wikipedia , lookup
Whooping cough wikipedia , lookup
Smallpox vaccine wikipedia , lookup
Vaccination policy wikipedia , lookup
Hepatitis C wikipedia , lookup
Childhood immunizations in the United States wikipedia , lookup
Transcript
Hepatitis B Virus (HBV) Vaccination Status Record Please indicate your Hepatitis B vaccine status below by signing the option that applies to you. Please return the form to: Michelle Lapo, RN, Health Services Kim Name (Please print) Employee Id # (short # on ID card) Department/Job title PLEASE CHOOSE ONE OF THE OPTIONS BELOW: OPTION 1 (Completed the vaccine series): ______ I have completed my HBV vaccinations through Skidmore College or an outside facility. Date of vaccinations: HBV #1________ HBV #2________ HBV #3 _______ Dates unknown: ______ Signature Date OPTION 2 (Need the vaccine): I would like to receive the HBV vaccination series and will call Health Service to discuss when to come in. Signature Date OPTION 3 (Decline the vaccine): I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and decide I want to be vaccinated against Hepatitis B, I can receive the vaccination series at no charge to me. Signature Date