Please fill out either CONSENT or DECLINE section below.
Please indicate if you consent to receive the hepatitis B vaccination.
I have read the information about the vaccine. I have had an opportunity to ask questions of a qualified medical professional and understand the benefits and risks of receiving the vaccination. I understand it is possible that I may not become immune, or that I may experience side effects from the vaccine.
Your consent to vaccination will be filed in your confidential medical record and will be retained for the duration of your employment plus 30 years.
Please indicate if you decline the hepatitis B vaccination.
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 have had an opportunity to ask questions of a qualified medical professional and understand the benefits and risks of receiving the vaccination. 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.
Your declination to vaccination will be filed in your confidential personnel record and will be retained for the duration of your employment plus 30 years.
