Download Bloodborne Pathogens Hepatitis B Vaccination – Declination Statement

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Transcript
The University of Louisiana at Monroe
Bloodborne Pathogens
Hepatitis B Vaccination – Declination Statement
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 I want to be vaccinated with hepatitis B
vaccine, I can receive the vaccination series at no charge to
me.
Employee Name (Print)
ULM Representative Name (Print)
Employee Signature
ULM Representative Signature
Job Title
Job Title
Date
Date