Laserfiche WebLink
DELTA BLOOD BANK <br />BIOSAFETY <br />HEPATITIS B VACCINE <br />EName Dept <br />I have read and understood the Biosafety Section "Infectious <br />Agents Transmitted by Blood" and have been informed of Delta <br />Blood Bank's Hepatitis B vaccination program. I do / do not <br />wish to have the hepatitis B vaccine at the blood bank's ex- <br />pense. <br />(signature of employee) (date) <br />------------------------------------------------------------- <br />If <br />applicable, complete section(s) <br />below: <br />------------------------------------------------------------ <br />ACTION DATE <br />RESULT <br />1. <br />Specimen for <br />Titer = <br />------------------------------------------------------------ <br />anti -HBs <br />Anti -HBc <br />2. <br />HBV vaccine <br />dose #1 <br />------------------------------------------------------------ <br />3. <br />HBV vaccine <br />dose #2 <br />------------------------------------------------------------ <br />4. <br />HBV vaccine <br />------------------------------------ <br />dose #3 <br />5. <br />Post vaccine <br />! ------------------------- <br />Titer <br />------------------------------------------------------------ <br />anti -HBs <br />Describe any adverse reaction: <br />Comments: <br />When this form has been completed, place in employee's <br />Confidential Personnel File. <br />BIOSAFETY - HBVFORM - 0491 - PRE -EXPOSURE <br />