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HEPATITIS B VACCINATION DECLINATION FORM

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.

HEPATITIS B DECLINATION
Employee: please check appropriate box, sign and date.

I have previously received the Hepatitis B vaccine and therefore decline.

I decline; however, I understand that should I decide to receive the vaccine at a future date I must be an active “at-risk” employee and initiate my request with the local branch.

I accept the offer to obtain the Hepatitis B vaccine and understand that I must be an active and eligible employee. Please send me the appropriate information.

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January 24, 2023 4:49 pm EDT

Hepatitis B Vaccination Uploaded by Assist Medical Staffing - staff@assistms.com IP 104.128.161.76

February 6, 2023 1:18 pm EDT

Document owner richard@assistms.com has handed over this document to staff@assistms.com 2023-02-06 13:18:39 - 104.128.161.231