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Employee Acceptance/Declination of Hepatitis B Vaccination 104tam-' 114 i Name � LJob Tale SS# School District Hepatitis B Vaccine Acceptance Hepatitis B virus typically causes a clinical illness with jaundice; it may also produce a sub- clinical infection. In either case, complications can occur, including persistence of infection, chronic carrier state, cirrhosis and liver cancer. Hepatitis B virus is transmitted principally through contaminated body fluids (especially blood) skin or mucosa; therefore, likelihood of contracting the disease is greater for individuals (e.g. nurses, athletic trainers) coming in frequent contact with blood or blood products. I understand that a vaccine for Hepatitis B is available and is being offered by my employer at no charge to me.This vaccine,when administered in three doses over a six-month period has been shown to be highly effective in providing protection against Hepatitis B infection. It has rarely produced serious side effects. I certify that I am not pregnant, nor am I a mother nursing a child with breast milk and that I have been given information regarding Hepatitis B vaccine and the opportunity to have questions answered. I agree to release my employer from any liability related to the administration of this vaccine. Signature Date Witness Date Dates of Vaccination: Hepatitis B Vaccine Declination I have received information from my employer Hepatitis B vaccine. about the I understand that due to any 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 vaccine at this time. 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-oscupational exposure to blood or other potentially infectious materials and I want be vaccin ted with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. gnature Date Witness Date