Grand Island Public Schools
123 South Webb Road
Grand Island, NE 68802
Your Legacy.
Their Opportunity.

Enhancing opportunities by seeking and securing resources for projects, scholarships and programs.

Access digital copies of our district flyers.

Improving school-to-home communication by distribute school flyers directly to families digitally.

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.

 

Check one

                              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:_________________

 

Media Inquiries
Jack Sheard, Marketing & Communications
308-385-5900 Ext. 1127
Grand Island Public Schools
123 South Webb Road
Grand Island, NE 68802
Your Legacy.
Their Opportunity.

Enhancing opportunities by seeking and securing resources for projects, scholarships and programs.

Access digital copies of our district flyers.

Improving school-to-home communication by distribute school flyers directly to families digitally.

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.

 

Check one

                              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:_________________

 

Media Inquiries
Jack Sheard, Marketing & Communications
308-385-5900 Ext. 1127
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