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Hepatitis B Virus (HBV) Vaccination Status Record Please indicate your Hepatitis B vaccine status below by signing the option that applies to you. Please return the form to: Michelle Lapo, RN, Health Services Kim Name (Please print) Employee Id # (short # on ID card) Department/Job title PLEASE CHOOSE ONE OF THE OPTIONS BELOW: OPTION 1 (Completed the vaccine series): ______ I have completed my HBV vaccinations through Skidmore College or an outside facility. Date of vaccinations: HBV #1________ HBV #2________ HBV #3 _______ Dates unknown: ______ Signature Date OPTION 2 (Need the vaccine): I would like to receive the HBV vaccination series and will call Health Service to discuss when to come in. Signature Date OPTION 3 (Decline the vaccine): 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 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 decide I want to be vaccinated against Hepatitis B, I can receive the vaccination series at no charge to me. Signature Date