Consent And Release For Hepatitis B Vaccination Form printable pdf download

Consent and Release for Hepatitis B Vaccination

Who Should Consider Receiving The Hepatitis B Vaccine?

In accordance with OSHA’s regulations, Pitt County Schools is offering the HBV vaccine free of charge to all employees who

may be exposed to human blood or other potentially infectious materials, and may result in possible exposure to bloodborne

pathogens. The following job classifications are included:

•

First Aid Responders

Plumbers

•

Health Occupations Teachers

Bus Drivers and Bus Monitors of exceptional children

•

School Health Nurses

Athletic Coaches and Trainers

•

Custodians

Designated Violence Intervention Personnel

•

Exceptional Children Teachers and Teacher Assistants

Social Workers

Who Should Not Get The Hepatitis B Vaccine?

•

Anyone allergic to yeast

Pregnant or breast-feeding mothers

•

Employees that have already received the Hepatitis B Vaccine

Vaccination Process

1. The employee will sign the Consent and Release for Hepatitis B Vaccination form as either accepting or declining. Please send the

completed form to Mike Whitford – Safety Coordinator.

2. Upon receipt of the above-mentioned consent form by the Safety Coordinator, the employee will be sent a signed Hepatitis B Vaccination

Verification sheet (SF-015). This will serve as notification to the Pitt County Health Department that the employee is currently employed

with Pitt County Schools.

3. When the employee receives the Hepatitis B Vaccination Verification sheet (SF-015), they will then contact the Pitt County

Health Department (252-902-2449) to establish an appointment for the administration of the Hepatitis B vaccination. The

employee will take the Hepatitis B Vaccination Verification sheet and their insurance card with them to their appointment at the

Pitt County Health Department. Prior to both the second and third appointments, the employee will need to contact the Safety

Coordinator to receive a new Hepatitis B Vaccination Verification for each appointment.

TO ACCEPT VACCINE

I understand that due to my potential occupational exposure to blood or other potentially infectious materials I may be at risk

of being infected by the Hepatitis B Virus (HBV). This is to certify that I have been informed about the symptoms and the

hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the

opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information

regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept

the Hepatitis B (HBV) vaccine. I understand I am responsible to schedule and complete the recommended series of shots.

Printed Name: _________________________ Signature: _________________________ Date: __________

School: _________________________

TO DECLINE VACCINE

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 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.

Printed Name: _________________________ Signature: _______________________ Date: __________

Please Send Completed Form To: Mike Whitford – Safety Coordinator

SF-013 Rev 003

Consent And Release For Hepatitis B Vaccination Form

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