Informed Consent For Inoculation - Hepatitis B Vaccine printable pdf download

INFORMED CONSENT FOR INOCULATION

HEPATITIS B VACCINE

I __________________________, acknowledge that Winning Wheels has made available

(employee’s name)

at no personal charge, the Hepatitis B Vaccine. Winning Wheels has authorized the Whiteside

County Health Department to administer the Hepatitis B Vaccine. The vaccine is available the

first and third Wednesdays of each month, from 1 to 4 p.m. Hepatitis B virus is an important cause

of viral hepatitis, and there is no specific treatment for this disease. The serious complications of

Hepatitis B virus infection include massive hepatic necrosis (death of liver cells), cirrhosis of the

liver, chronic active hepatitis and hepatiocellular carcinoma. Transmission of Hepatitis B virus

infection is often associated with close interpersonal contact with an individual. Although Hepatitis

B virus is usually transmitted through blood and blood products, it has been found in tears, saliva,

urine, semen and vaginal secretions. Responsiveness to the vaccine is related to a person’s age.

20-39 years old = 95% - 99%

Over 40 years old = 91%

Hepatitis B vaccine will not prevent hepatitis caused by other agents, such as Hepatitis A virus, non-

A, non-B Hepatitis viruses, or other viruses known to infect the liver.

ADVERSE REACTIONS

Hepatitis B vaccine is generally well tolerated. No serious adverse reactions attributable to the

vaccine have been reported during the course of clinical trails. Fifteen to seventeen percent (15% -

17%) of a trial group of individuals reported some complaints.

The most common of these are:

Injection site soreness

Weakness, headache, fever

Nausea and/or Diarrhea

Dizziness

Sweating, achiness, sense of warmth, chills

Vomiting, Decreases Appetite

The vaccine is administered in three (3) doses:

dose within 10 days of employment

dose 1 month later

dose 6 months after first dose

I have read this information and all questions regarding the safety, risk and effectiveness of Hepatitis

B vaccine have been answered to my satisfaction.

I hereby, ( ) accept, ( ) decline, *the offer of immunization with Hepatitis B vaccine.

*SEE DECLINATION STATEMENT

If the employee fails to follow through with the administration of the vaccine at the scheduled

intervals, such action will signify the employee’s decision to decline the vaccine and will release the

employer from further obligation.

Signed _________________________________ Date __________________

Informed Consent For Inoculation - Hepatitis B Vaccine