Hepatitis B Vaccination: Consent/Declination Form

Please Choose One

Consent: As a health care professional having occupational exposure to blood or other potentially infections materials which includes the risk of acquiring Hepatitis B virus (HBV V) Infection, I have been informed about and offered the opportunity to receive the Hepatitis B vaccine at no charge to me at my doctor’s office. I understand that I must have three 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 an adverse side effect from the vaccine. I accept the offer at this and will obtain vaccine at my doctor’s office.

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 me. 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 it at my physician’s office at no charge to me.

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

I have previously received the complete Hepatitis B vaccination series

Other/explainOther/explain

Section

MEASLES, MUMPS, RUBELLA IMMUNITY STATUS

1. Were you born after 1957?

Yes (if yes, go to number 2 and complete)

No (If no, sign below and submit)

2. I have had: Measles

Yes

Unknown

Mumps

Yes

Unknown

Rubella

Yes

Unknown

Employee Name

Date

SS#

Signature

Clear

HEPATITIS B VACCINATION

CONSENT /DECLINATION FORM

Section

MEASLES, MUMPS, RUBELLA IMMUNITY STATUS

Pages

Services

Employees