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
Health Occupations Teachers
Bus Drivers and Bus Monitors of exceptional children
School Health Nurses
Athletic Coaches and Trainers
Designated Violence Intervention Personnel
Exceptional Children Teachers and Teacher Assistants
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
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: __________
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