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DATE: _______________________
EMPLOYEE NAME: ____________________________________
EMPLOYEE ID #: ______________________________________
I understand that due to my occupational exposure to blood or other potential infectious
materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given
the opportunity at Goucher College to be vaccinated with Hepatitis B vaccine, at no charge
to myself. However, I decline the Hepatitis B vaccination at this time. I understand that if I
decline the vaccine offered by the College, 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 at no charge to me.
Employee Signature
Facility Representative Signature
I have _________ have not _________ previously received the Hepatitis B vaccine on
_____________________________________________(insert dates of vaccinations).