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 DECLINATIONEmployee: 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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Document Name: Hepatitis B Vaccination
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