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Transcript
University of New Hampshire Bloodborne Pathogen Exposure Control Plan Training and Vaccination Form Please complete sections 1 & 2 below 1. [ ] I have received training on the risks of working with human blood or other potentially infectious materials as outlined in the University of New Hampshire’s Bloodborne Pathogen Exposure Control Plan. HEPATITIS B VACCINATION ACCEPTANCE/DECLINATION STATEMENT 2. In full recognition of the above (check one of the following): [ ] I have already received the HBV vaccination series on: _________________. Date/Year [ ] I decline participation in the vaccination series. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the 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 the Hepatitis B vaccination at this time. I understand that by declining this vaccination, 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 wish to be offered the Hepatitis B vaccine, I can be vaccinated at that time at no charge to me. [ ] I accept participation in the hepatitis B program and wish to receive the vaccination series. _________________________________ Print Name ______________________________________ Signature _________________________________ Department ______________________________________ Date Updated 3/2012