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Hepatitis accination Acceptance or Declination Form Instructions: Complete the information below. Check either the "Acceptance" or "Declination" section and give to your -manager 1or email to uniontatlto1o209@gmaii.com Name Date Please Check One of the Following: _I Accept the Hepatitis B Vaccination I have been informed of the biological hazards that exist in my workplace, and I understand the risks of exposure to blood or other potentially infectious materials involved with my job. I understand that I may be at risk of acquiring hepatitis B virus (HBV) infection. I acknowledge that I have been provided information on the hepatitis B vaccine, including information on its effectiveness, safety, method of administration and the benefits of being vaccinated. I have been given the opportunity to be vaccinated with the hepatitis B vaccine at no charge to myself. I understand that I am responsible for scheduling and keeping my appointments to receive the Hepatitis B vaccine in accordance with the recommended series (three vaccination series; second vaccine one month after first vaccine; and third vaccine within five months of second vaccine). EH&S will provide you with an "Authorization Letter" to obtain vaccine for no charge. _I Decline the Hepatitis B Vaccination I understand that due to my occupational exposure to blood or other potentially infectious material (OPIM) 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 myself. However, I decline hepatitis B vaccination 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 continue to have occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Please check one of the following if you are declining: —1 am declining because I have previously completed the hepatitis B vaccination series. V I am declining because I choose not to have the hepatitis B vaccination series. I am also aware that I may c urge my min at later date. - �/ ' 7L, Sig nat a Date R Hepatitis accination Acceptance or Declination Form Instructions: Complete the information below. Check either the "Acceptance" or "Declination" section and give to your -manager 1or email to uniontatlto1o209@gmaii.com Name Date Please Check One of the Following: _I Accept the Hepatitis B Vaccination I have been informed of the biological hazards that exist in my workplace, and I understand the risks of exposure to blood or other potentially infectious materials involved with my job. I understand that I may be at risk of acquiring hepatitis B virus (HBV) infection. I acknowledge that I have been provided information on the hepatitis B vaccine, including information on its effectiveness, safety, method of administration and the benefits of being vaccinated. I have been given the opportunity to be vaccinated with the hepatitis B vaccine at no charge to myself. I understand that I am responsible for scheduling and keeping my appointments to receive the Hepatitis B vaccine in accordance with the recommended series (three vaccination series; second vaccine one month after first vaccine; and third vaccine within five months of second vaccine). EH&S will provide you with an "Authorization Letter" to obtain vaccine for no charge. _I Decline the Hepatitis B Vaccination I understand that due to my occupational exposure to blood or other potentially infectious material (OPIM) 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 myself. However, I decline hepatitis B vaccination 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 continue to have occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Please check one of the following if you are declining: —1 am declining because I have previously completed the hepatitis B vaccination series. V I am declining because I choose not to have the hepatitis B vaccination series. I am also aware that I may c urge my min at later date. - �/ ' 7L, Sig nat a Date