Laserfiche WebLink
Hepatitis B Vaccine Declination Form <br /> ChapterUse with <br /> Facility Name: 46r kw <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials (OPIM), I may be at risk of acquiring hepatitis B virus(HBV) <br /> infection. <br /> You have given me the opportunity to be vaccinated with the hepatitis B vaccine, at <br /> no charge to myself. <br /> However, I decline hepatitis B vaccination at this time. I understand that by declining <br /> this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If, <br /> in the future, I continue to have occupational exposure to blood or other potentially <br /> infectious materials, and I want to be vaccinated with hepatitis B vaccine, I can <br /> receive the vaccination series at no charge to me. <br /> ❑ I have already received the hepatitis B vaccination series. <br /> LCL Ael'- <br /> E loyee's Name (Print) j <br /> Employee's Signature <br /> Date ► <br /> t <br /> i <br /> hitp://www.Ini.wa.gov/ <br /> R-6 i� <br /> 09/04 f <br /> I <br />