Download David Newton - Huntington Lake Volunteer Fire Department

Huntington Lake Volunteer Fire Department
DELCLINATION - RECORD OF HEPATITIS “B” VACCINE 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 charge to me. 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.
Check here if you have been previously vaccinated for Hepatitis B
Print Name:
David Newton
Employee Signature:
Date:
Employer Representative:
DELCLINATION - RECORD OF TUBERCULOSIS TESTING DECLINATION
TB Testing Declination Statement
I understand that due to my occupational exposure to aerosol transmissible diseases, I may be
at risk of acquiring infection with tuberculosis. I have been given the opportunity to be tested
annually for this disease at no charge to me. However, I decline annual testing at this time and
understand that the fire department will provide testing for me at no charge in the future if I so
choose.
David Newton
Employee Signature
Date
DELCLINATION - RECORD OF HEPATITIS “B” VACCINE 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 charge to me. 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.
Check here if you have been previously vaccinated for Hepatitis B
Print Name:
Elaine Newton
Employee Signature:
Date:
Employer Representative:
DELCLINATION - RECORD OF TUBERCULOSIS TESTING DECLINATION
TB Testing Declination Statement
I understand that due to my occupational exposure to aerosol transmissible diseases, I may be
at risk of acquiring infection with tuberculosis. I have been given the opportunity to be tested
annually for this disease at no charge to me. However, I decline annual testing at this time and
understand that the fire department will provide testing for me at no charge in the future if I so
choose.
Elaine Newton
Employee Signature
Date
DELCLINATION - RECORD OF HEPATITIS “B” VACCINE 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 charge to me. 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.
Check here if you have been previously vaccinated for Hepatitis B
Print Name:
Mark Richards
Employee Signature:
Date:
Employer Representative:
DELCLINATION - RECORD OF TUBERCULOSIS TESTING DECLINATION
TB Testing Declination Statement
I understand that due to my occupational exposure to aerosol transmissible diseases, I may be
at risk of acquiring infection with tuberculosis. I have been given the opportunity to be tested
annually for this disease at no charge to me. However, I decline annual testing at this time and
understand that the fire department will provide testing for me at no charge in the future if I so
choose.
Mark Richards
Employee Signature
Date
DELCLINATION - RECORD OF HEPATITIS “B” VACCINE 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 charge to me. 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.
Check here if you have been previously vaccinated for Hepatitis B
Print Name:
Mitzi Richards
Employee Signature:
Date:
Employer Representative:
DELCLINATION - RECORD OF TUBERCULOSIS TESTING DECLINATION
TB Testing Declination Statement
I understand that due to my occupational exposure to aerosol transmissible diseases, I may be
at risk of acquiring infection with tuberculosis. I have been given the opportunity to be tested
annually for this disease at no charge to me. However, I decline annual testing at this time and
understand that the fire department will provide testing for me at no charge in the future if I so
choose.
Mitzi Richards
Employee Signature
Date