Hepatitis B Vaccine Refusal printable pdf download

Hepatitis B Vaccine Refusal

Goodwin College

Department of Health and Natural Sciences

One Riverside Drive

East Hartford, CT 06118

Hepatitis B Vaccine Refusal

Hepatitis B is a virus transmitted through blood and other body fluids. The virus

is the cause of Hepatitis B, a serious liver disease.

I understand that due to my

occupational exposure to blood and other potentially infected materials, I may be at risk

for acquiring Hepatitis B virus (HBV) while studying to be a Medical Assisting student at

Goodwin College. I understand that specific courses, including but not limited to MED

153 – Medical Assisting: Laboratory Procedures, Pharmacology, and Internship require

the use of needles and exposure to blood and other potentially infectious materials.

I have read and understood the risks of Hepatitis B. However, I decline the

Hepatitis B vaccination at this time. I understand that by declining the vaccination I

continue to be at risk for acquiring Hepatitis B.

__________________________________________

Student Name

__________________________________________

Date _______

Student Signature

__________________________________________

Date _______

Medical Assisting Program Director Signature

Hepatitis B Vaccination Refusal Form

Rev. 1/2010

Hepatitis B Vaccine Refusal