Hepatitis B Consent or Declination Form

Appendix A – Hepatitis B Consent or Declination Form

CONFIDENTIAL

Employee Full Name

Phone

Gender

Male

Female

Birthdate (MM/DD/YY)

Have you received all three doses of the Hepatitis B vaccine?

Yes

If you consent to receive the hepatitis B vaccination:

I have read the information about the vaccine. I have had an opportunity to ask questions of a qualified medical professional and understand the benefits and risks of receiving the vaccination. I understand it is possible that I may not become immune, or that I may experience side effects from the vaccine.

If you decline the hepatitis B vaccination:

I understand that due to my occupational exposure to blood or other potentially infectious materials 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 me; however, I decline hepatitis B vaccination at this time. I have had an opportunity to ask questions of a qualified medical professional and understand the benefits and risks of receiving the vaccination. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Please indicate whether you consent or decline to receive the hepatitis B vaccination:

Yes, I consent

No, I decline

Signature

Date Signed

Your consent or declination to vaccination will be filed in your confidential personnel record and will be retained for the duration of your employment plus 30 years.

Thanks for submitting!