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Transcript
Employee Immunization Exemption Form The employee immunity policy has been explained to me, and all of my questions have been answered. I understand that in the event of a disease outbreak, I may be reassigned temporarily, or I may not be allowed to work during the period defined as an outbreak. I request an exemption from the following immunizations(s): Immunization: ____________________ Medical Religious Immunization: ____________________ Medical Religious Immunization: ____________________ Medical Religious Immunization: ____________________ Medical Religious Immunization: ____________________ Medical Religious HEPATITIS B VACCINATION DECLINATION 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 cost 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. I elect to: (check one) Receive the Vaccination Decline the Vaccination My choice not to participate will in no way affect my employment status. Date: ________________________ Employee Name: (Print): __________________________________ Employee Signature: ______________________________________