Download 4.1-B Hepatitis B Refusal/Request Form

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