* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Hepatitis B declination form - Office of Clinical Partnerships
Common cold wikipedia , lookup
Immunocontraception wikipedia , lookup
Sociality and disease transmission wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Neonatal infection wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Marburg virus disease wikipedia , lookup
Transmission (medicine) wikipedia , lookup
Vaccination policy wikipedia , lookup
Childhood immunizations in the United States wikipedia , lookup
Infection control wikipedia , lookup
Vaccination wikipedia , lookup
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