Laserfiche WebLink
Hepatitis B Vaccine Declination Form <br />Facility Name: <br />Facility Address: <br />/ 2 M 0NKC + S T�TTID� <br />q C 1. N. c- FN-tzj -t_ 6( --VT). -MAL v C A L <br />understand that due to my occupational exposure to blood or other potentially <br />infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. <br />I have been given the opportunity to be vaccinated with the hepatitis B vaccine, <br />at no charge to myself. <br />However, I decline hepatitis B vaccination at this time. I understand that by <br />declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious <br />disease. If, in the future, I continue to have occupational exposure to blood or <br />other potentially infectious materials, and I want to be vaccinated with hepatitis B <br />vaccine, I can receive the vaccination series at no charge to me. <br />Employe 's N e (Print) <br />i <br />Employee's Skature <br />l31 <br />Dat <br />