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Download Hepatitis B Vaccination Declination Form Name. _______________________________________________________
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Transcript
Hepatitis B Vaccination Declination Form Name. _______________________________________________________ Department ______________________ Last 4 digits of SS# _________ THE FOLLOWING MUST BE SIGNED BY THE EMPLOYEE IF HEPATITIS B VACCINATION IS REFUSED. 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 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. _____________________________________ _______________________ Signature Date Rev 11/00
