Hepatitis B Vaccination

Hepatitis B Vaccination <hr />Consent/DeclinationAs an employee having occupational exposure to potentially infectious materials, you will have the right to receive the Hepatitis B vaccination series, free of cost to you. Please read the Hepatitis B Vaccination information sheet and complete this form by checking the box preceding the appropriate statement and signing, dating, and indicating your Social Security Number at the bottom- Upon completion, please return document to the Company. Thank you!

CONSENT: As a healthcare professional having occupational exposure to blood or other potential infectious material, which includes the risk of acquiring Hepatitis B virus (H8V) infection, I have been informed about and offered the opportunity to waive the Hepatitis B vaccine (to be paid for by my current employer). I understand that I must have 3 doses of vaccine to develop immunity. however as with any medical treatment, there is no guarantee that I will become immune or that I will not experience any adverse side effect from the vaccine. I accept the offer at this Time.

DECLINATION: 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. 1 know this continues to put me at risk, but if in the future, while actively working with the Company. 1 continue to have occupational exposure to blood or other potentially infectious materials and 1 want to be vaccinated with hepatitis B vaccine, I can receive it at no charge to me.

I am declining the opportunity to receive the Hepatitis B vaccination series for the following reason: (please select one)

I have previously received the complete Hepatitis B vaccination series.

Antibody testing has revealed ł am immune to Hepatitis B. (Please submit laboratory numerical proof of immunity)

The vaccine is contraindicated for medical reason(s): (please describe)

Other, explain:

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