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Hepatitis B Vaccination Acceptance or Declination Form <br />Instructions: <br />Complete the information below. Check either the "Acceptance" or "Declination" section and <br />give to your manager o,�rlem it to uniontattoo209@gmaii.com <br />Name ,Jt)('aJ� 17j�all%� <br />Date 7 Zz <br />Please Check One of the Following: <br />_I Accept the Hepatitis B Vaccination <br />I have been informed of the biological hazards that exist in my workplace, and I understand <br />the risks of exposure to blood or other potentially infectious materials involved with my <br />job. I understand that I may be at risk of acquiring hepatitis B virus (HBV) infection. I <br />acknowledge that I have been provided information on the hepatitis B vaccine, including <br />information on its effectiveness, safety, method of administration and the benefits of being <br />vaccinated. I have been given the opportunity to be vaccinated with the hepatitis B vaccine <br />aA no charge to myself. I understand that I am responsible for scheduling and keeping my <br />appointments to receive the Hepatitis B vaccine in accordance with the recommended <br />series (three vaccination series; second vaccine one month after first vaccine; and third <br />vaccine within five months of second vaccine). EH&S will provide you with an "Authorization <br />Letter" to obtain vaccine for no charge. <br />V I Decline the Hepatitis B Vaccination <br />I understand that due to my occupational exposure to blood or other potentially infectious <br />material (OPIM) I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been <br />given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. <br />However, I decline hepatitis B vaccination at this time. I understand that by declining this <br />vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I <br />continue to have occupational exposure to blood or OPIM and I want to be vaccinated with <br />hepatitis B vaccine, I can receive the vaccination series at no charge to me. <br />Pleas <br />e check one of the following if you are declining: <br />_I am declining because I have previously completed the hepatitis B vaccination series. <br />✓I a decli 'ng because I choose not to have the hepatitis B vaccination series. I am also <br />a ar that a change my mind at a later date. <br />7 ZL <br />ign ur Date <br />