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Transcript
DEPARTMENT OF OCCUPATIONAL THERAPY 601 MARTIN LUTHER KING JR DRIVE, WINSTON-SALEM, NC 27110 (336) 750-3185– PHONE • (336) 750-3173 – FAX • [email protected] HEPATITIS B VACCINE DECLINATION 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 informed about the risks and understand that by declining the vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I wish to get the vaccination I am free to decide to do so. __________________________________________ ____________________________ Student’s Signature Date Winston-Salem State University Is A Constituent Institution Of The University Of North Carolina An Equal Opportunity Employer
