Hepatitis A & B Vaccination Consent/Decline


Hepatitis A & B Vaccination

Consent/Decline

  

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis A and B virus (HAV/HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis A and B vaccine, at no charge to myself.

 

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                              I hereby authorize my employer to vaccinate me against Hepatitis A & B virus (HAV/HBV). I understand that the injections are given over a period of months before they are effective in preventing this disease.

 

 

                              I decline Hepatitis A & B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis A or B, a serious diseases. 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 A & B vaccine, I can receive the vaccination series at no charge to me.

 

 

 

Employee Name: _________________________________________

                                                                                          (Please Print)

 

Employee Signature:_______________________________________

 

Job Title:________________________________________________

 

Social Security Number:____________________________________

 

Date:_________________