Sample Hepatitis B Consent/refusal Form Hepatitis B Birth Dose Vaccination printable pdf download

Sample Hepatitis B Consent/refusal Form Hepatitis B Birth Dose Vaccination

Medical Facility Letterhead

Addressograph/Newborn’s

information

SAMPLE HEPATITIS B CONSENT/REFUSAL FORM

HEPATITIS B BIRTH DOSE VACCINATION

The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics

(AAP) recommend that a birth dose of hepatitis B vaccine be administered to all infants born in the

United States. The New York State Department of Health has established that this hepatitis B vaccine

birth dose be given within 12 hours of birth as the standard of care in New York State. As with all

childhood immunizations, a parental consent is necessary. Also, the Hepatitis B Vaccine Information

Statement (VIS) must be provided to the parent prior to vaccination and the publication date of the VIS

must be documented.

Publication date of VIS provided to parent: __February 2, 2012 (Interim)_

Verbal consent obtained RN signature: _______________________________ OR

I give consent for my infant __________________________ to be given a birth dose of hepatitis B

vaccine. I have received the Hepatitis B Vaccine Information Statement and understand the risks

and benefits of my child receiving the vaccine.

Parent Signature: ______________________________________

Date: _______________

Witness Signature: ______________________________________

Date: _______________

Hepatitis B Vaccine 0.5 ml dose

Date of administration: ________________ Time: ___________ Site: __________________

Manufacturer/Vaccine Trade Name: ___________________________________

Lot #: _____________________________ Expiration Date: _______________

Administered by: ___________________________________________________ OR

I understand the risks of hepatitis B and refuse to have my child receive the hepatitis B vaccine. My

child’s physician will receive a copy of this form.

Reason for refusing vaccination: __________________________________________________________

Parent Signature:

______________________________________

Witness Signature: ______________________________________

Sample Hepatitis B Consent/refusal Form Hepatitis B Birth Dose Vaccination