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Transcript
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