Bloodborne Pathogens
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2Bloodborne Pathogens
PART 1: HEPATITIS B VACCINATION FORM
OSHA states that the hepatitis B Virus vaccination shall be offered to all employees occupationally
exposed to blood or other potentially infectious materials, unless the employee has a previous HBV
vaccination or unless antibody testing has revealed the employee is immune. OSHA recommends
those at risk be immunized against HBV. The immunization regime consists of three doses of vaccine
given according to the following schedule:
st
1
dose at elected date within 24 hours after exposure
nd
2
dose 1 month later
rd
st
3
dose 6 months after 1
dose
th
4
dose blood testing for B surface antibody (optional)
or after possible exposure (must be within 24 hours of possible exposure.)
PRECAUTIONS
Listed here are some precautions for you to discuss with your physician prior to talking HBV
vaccination:
•
Currently or possibly pregnant
•
Allergy to Formalin
•
Currently have an active infection which includes fever
•
Have immunodeficiency or receiving immune-suppressive therapy
CONSENT/REFUSAL FOR VACCINATION
(please check appropriate boxes)
A. [ ] I have read the above items and request vaccination by a healthcare provider paid for by SCU
(Please sign the Part 1 Hepatitis B Vaccination form).
B. [ ] I have been vaccinated previously and do not request vaccination through SCU (Please sign
the Part 1 Hepatitis B Vaccination form).
C. [ ] I fully understand the importance of being adequately immunized against hepatitis virus,
however I elect not to be immunized at this time (please sign the Part 2 Hepatitis B Vaccination
Declination form).
Your Signature:
Please Print your name:
Date: ___________________
Faculty and Staff:
Completed Status Form should be turned in to Human Resources.
Students:
Completed Status Form should be turned in to Cowell Health
SCU Bloodborne Pathogens (Nov. 18, 2013)
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