Download 3:30 - 4:15 pm

2016-17 HEPATITIS B VACCINATION SCHEDULE & FORM
Date
Thursday, 9/13/2016
Tuesday, 10/11/2016
Tuesday, 11/15/2016
Tuesday, 12/13/2016
Tuesday, 1/17/2017
Tuesday, 2/14/2017
Tuesday, 3/14/2017
Tuesday, 4/25/17
Tuesday, 5/16/17
Time
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
3:30 - 4:15 p.m.
All vaccination clinics held at:
Doyle Administration Building
545 W Dayton St
Room 129
You must call Health Services at 663-8437 five days in
advance to reserve your vaccine dose
Designated employees listed below must complete MMSD’s Hepatitis B vaccination series or this form. If
completing this form, use section (A) Vaccination Information, to confirm you have already received the Hepatitis B
vaccine, or (B) Vaccination Declination to indicate you are declining the vaccine.
 All Custodians
 All Elementary Secretaries
 All School Building Administrators
 All Nurses and Nurse’s Assistants
 All Physical Education Teachers
 All School Security Assistants
 All Special Education Teachers and Assistants
 All Substitute Special Education Assistants
________________________________________________________________________________________
(A) VACCINATION INFORMATION
 I have received the Hepatitis B vaccination series from another health provider on the following dates:
#1: _______________ (mm/dd/yy)
Given at: __________________________________________
#2: _______________ (mm/dd/yy)
Given at: __________________________________________
#3: _______________ (mm/dd/yy)
Given at: __________________________________________
(B) VACCINATION DECLINATION
 I am declining to be vaccinated. 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 infection. I have been given the
opportunity to be vaccinated with hepatitis B vaccine, at no charge 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.
Name (print): _________________________________________________ “B” Number: __________________
Signature: ____________________________________________________ Date: _________________________
Rev: 4/3/17