Laserfiche WebLink
Hepatitis B Vaccine Declination <br />I understand that due to my occupational exposure to blood or other potentially infectious materials, I <br />may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be <br />vaccinated with hepatitis B vaccine, however, I decline hepatitis B vaccination at this time. I understand <br />that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the <br />future I continue to have occupational exposure to blood or other potentially infectious materials and I <br />want to be vaccinated, I can receive the vaccination series. <br />California Code of Regulations, Title 8, section 5193, subsection (f) (2) (D) <br />I decline the Hepatitis B Vaccination Series due to the following reason(s): <br />(Please mark at least one choice) <br />C9 I am declining because I choose not to have the hepatitis B vaccination series. I am aware that <br />I may change my mind at a later date. <br />❑ I have completed the entire series of hepatitis B vaccinations. I have a record or know the date <br />and location of those vaccinations. <br />❑ I have already completed the entire hepatitis B vaccination series. I do not have a record or <br />cannot recall when I received the vaccination. <br />❑ I have a positive hepatitis B surface antibody titer. <br />❑ Other <br />12 15 ZI <br />Signature Date <br />Ckelsea Cornwe(I <br />816`90 <br />Date of Birth <br />Print Name Job Title/Department <br />