Hepatitis B Vaccination Declination Form printable pdf download

Hepatitis B Vaccination Declination Form

Please complete the appropriate section below, maintain a copy for your records, and send a copy to

the Claremont University Consortium (CUC) Human Resources Office. This will initiate request for

vaccination or document declination of the Hepatitis B vaccine. Records should be retained for the

duration of employment.

In accordance with the Cal/OSHA Bloodborne Pathogen Standard, CUC will make available the

Hepatitis B vaccine and vaccination series to all employees who have occupational exposure to blood

and other potentially infectious materials. CUC will provide the vaccination series at no charge to the

employee. All employees who qualify for vaccination have the option to accept or decline.

EMPLOYEE NAME: ___________________________

EMPLOYEE ID:

___________________________

DEPARTMENT:

___________________________

JOB TITLE:

___________________________

PHONE NUMBER:

___________________________

________ Check here if you have been immunized.

________ Date immunization received.

HEPATITIS B VACCINE DECLINATION

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 may 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 by contacting the Student Health Services

Physician.

_____________________Employee's Signature

______________Date

Hepatitis B Vaccination Declination Form