Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Hepatitis B Vaccine Declination Form
Document related concepts
Common cold wikipedia , lookup
Sociality and disease transmission wikipedia , lookup
Thiomersal controversy wikipedia , lookup
Neonatal infection wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Herd immunity wikipedia , lookup
Globalization and disease wikipedia , lookup
Transmission (medicine) wikipedia , lookup
Immunocontraception wikipedia , lookup
Infection control wikipedia , lookup
Whooping cough wikipedia , lookup
Vaccination policy wikipedia , lookup
Smallpox vaccine wikipedia , lookup
Childhood immunizations in the United States wikipedia , lookup
Hepatitis C wikipedia , lookup
Transcript
Hepatitis B Vaccine Declination Form Form Number/Rev # EHS-00012-F5 R3 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 the Hepatitis B vaccine, I can receive the vaccination series at no charge to me. Name (Please PRINT): Signature: Date : Printed copies are considered uncontrolled. Verify revision prior to use. DCN0974 CNSE Confidential When Completed Page 1 of 1
