Hepatitis B Vaccination Declination Form printable pdf download

Hepatitis B Vaccination Declination Form

Name. _______________________________________________________

Department ______________________ Last 4 digits of SS# _________

THE FOLLOWING MUST BE SIGNED BY THE EMPLOYEE IF HEPATITIS B

VACCINATION IS REFUSED.

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 continue to be at

risk of acquiring hepatitis B, a serious disease. If in the future 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 want to be vaccinated with Hepatitis b vaccine, I can

receive the vaccination series at no charge to me.

_____________________________________ _______________________

Signature

Date

Rev 11/00

Hepatitis B Vaccination Declination Form