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Download 4.1-B Hepatitis B Refusal/Request Form
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Transcript
CITY OF DELAND DELAND POLICE DEPARTMENT William E. Ridgway Chief of Police Print Name: _______________________________ Last 4 SS# ___________________ HEPATITIS B Declination/request for inoculation 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, free of charge. However, I decline the 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 free of charge; will all costs incurred for these inoculation paid for by the City of DeLand. Signature: _____________________________________ Date: ___________________ I decline the hepatitis B (HBV) vaccine at this time as I have already received my inoculation and it is current. Signature: _____________________________________ Date: ___________________ I would like to request the hepatitis B (HBV) vaccination series. Signature: _____________________________________ Date: ___________________ I would like to request the antibody (titer) test to determine immunity. Signature: _____________________________________ Date: ___________________ 4.1-B 219 West Howry Avenue DeLand, FL 32720 (386) 626-7400 Fax (386)740-6842