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APPENDIX D: Hepatitis B Vaccine Consent Form Oa Lfile sc . , Consent for Hepatitis B Vaccine I have read and understand the Hepatitis B Information Sheet(s) which describes both the clinical course of the disease and its risks and hazards, and the vaccination and its usual and most frequent risks and hazards. I have discussed any concerns or questions with the Licensed Health Care Provider. To the best of my knowledge ,I am not pregnant; if I am pregnant 1 have consulted my private physician and obtained written authorization for vaccination (a copy of which is attached to this consent form.) I understand that there is no guarantee that vaccination will be effective or that my vaccination will be free of side effects. I understand that my participation in the Hepatitis B Vaccination Program is entirely voluntary, although recommended for me, because: I am in a work environment at Life Line Screening that presents a reasonable anticipation of my exposure to potentially infectious materials; I have had a possible occupational exposure to blood or other potentially infectious materials. I have opted to receive the Hepatitis B Vaccine (synthetic.) I hereby consent to the administration of the Hepatitis B Vaccine to be given by over the next 6 months. I understand that I must receive three doses of vaccine to confer immunity. Employee Name: Employee Signature: Date: Employee Social Security Number: Witness Name: Witness Signature: Date: Employee Name: Work Phone: Home Phone: Home Address: City: State: Zip: Social Security Number: Date of Birth: Name of Immediate Supervisor: Signature of Immediate Supervisor: Date: Date Vaccinated: Lot M Site of Injection: Date Vaccinated: Lot M Site of Injection: Date Vaccinated: Lot M Site of Injection: 12