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Get Hepatitis B Vaccine Acceptance/Declination Form

HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM ACCEPTANCE I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens including Human Immunodeficiency Virus HIV and Hepatitis B Virus HBV. This is to certify that I have been informed about the symptoms and the hazards associated with these viruses as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself* In addition I have received information regarding the Hepatitis B HBV vaccine. Based on the training I have received I am making an informed decision to accept the Hepatitis B HBV vaccine. DECLINATION 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 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. CHECK ONE I ACCEPT Hepatitis B vaccine inoculation OR I DECLINE Hepatitis B vaccine inoculation* Employee s Name Employee s Signature Date Witness Signature. This is to certify that I have been informed about the symptoms and the hazards associated with these viruses as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself* In addition I have received information regarding the Hepatitis B HBV vaccine. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself* In addition I have received information regarding the Hepatitis B HBV vaccine. Based on the training I have received I am making an informed decision to accept the Hepatitis B HBV vaccine. Based on the training I have received I am making an informed decision to accept the Hepatitis B HBV vaccine. DECLINATION 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. DECLINATION 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 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. I 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. CHECK ONE I ACCEPT Hepatitis B vaccine inoculation OR I DECLINE Hepatitis B vaccine inoculation* Employee s Name Employee s Signature Date Witness Signature. .

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