Download Hepatitis B Letter of Declination

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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
occupational.health@ucdenver.edu
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