Download Hepatitis B declination form - Office of Clinical Partnerships

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Transcript
Pre-Health Internship Program
Hepatitis B 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. However, I decline
hepatitis B vaccination at this time. I understand that by declining to be vaccinated, I continue
to be at risk of acquiring hepatitis B. If in the future, I continue to have occupational exposure
to blood or other potentially infectious materials, I may want to be vaccinated with hepatitis B
vaccine. I understand that this vaccination will be at my expense.
Student Name: __________________________________________________________
Address: _______________________________________________________________
City/State/Zip: __________________________________________________________
Phone Number: _________________________________________________________
ASU Email Address: ______________________________________________________
Student Signature: _______________________________________________________
Date: ___________________________
The Office of Clinical Partnerships
Interdisciplinary A Bldg., Room A121
P.O. Box 877805, Tempe, AZ 85287-7805
TEL: (480)727-4765
FAX: (965-0723