Hepatitis B Vaccine Declination printable pdf download

Hepatitis B Vaccine Declination

W A S H I N G T O N S T A T E U N I V E R S I T Y C O L L E G E O F N U R S I N G |

G R A D U A T E P R O G R A M S

HEPATITIS B VACCINE DECLINATION

I understand that due to my exposure to potentially infectious materials in my nursing

courses, I may be at risk of acquiring Hepatitis B (HBV) infection.

I understand that by declining to obtain this vaccine, I continue to 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 have

been vaccinated with the Hepatitis B vaccine, I will present notification to the Graduate

Program Office, College of Nursing, Room 133.

NAME (please print): _______________________________________________

SIGNATURE: _______________________________________________________

DATE: _____________________________________________________________

Please scan your completed form, save it as a PDF document, then upload it to E*Value.

If you have questions or need assistance with this process, please contact:

SPOKANE/YAKIMA/WALLA WALLA/TRI-CITIES

Rychelle Wagner | 509-324-7445 |

rmwagner@wsu.edu

VANCOUVER

Kathleen Fias | 360-546-9752 |

kathleen.fias@vancouver.wsu.edu

Hepatitis B Vaccine Declination