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Campus address: 135 College Street, Suite 100 New Haven, Connecticut 06510-2411 Yale University Telephone: 203 785-355 Fax: 203-785-7588 HEPATITIS B VACCINE NOTIFICATION FORM 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 have declined 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. Yes, I wish to be vaccinated against Hepatitis B if recommended by the Department of Employee Health. Employee Health walk in hours are 1:30-4:00 pm on Monday, Tuesday, Wednesday and Friday. To make an appointment, call 203-432-7978. I have already received the Hepatitis B vaccine. Please send this information to the Employee Health Office. You can drop off your record, or mail or fax this information to: Employee Health, 55 Lock Street, P.O. Box 208237, New Haven, CT 06520-8237, Fax: 203432-7828 Name (Please Print) Signature Department NETID# Campus address Date Telephone (8:30 a.m. - 5:00 p.m.) Please return completed copy to: Environmental Health & Safety Bloodborne Pathogen Program 135 College Street, Suite 100 New Haven, CT 06511-2411 For Office Use Only 4/19/13