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Instructions: Complete the Employee/Student information below. Determine whether or not you wish to receive the vaccine at no charge by checking either the ? ... Forms: ? Bloodborne Pathogen Exposure Emergency Checklist- For Use in a Collegedecline to accept the HBV vaccination, shall sign a statement declaring.Routine booster doses of the hepatitis B vaccine, if recommended by the U.S.by the availability of prophylactic immunization and must have on-file ... PROPOSER's firm shall be indicated on the cover of each proposal. Additionally, PROPOSER shall submit one (1) electronic copy in PDF or MS Word format on a ... If the employee refuses the vaccines, as signed declination will be placed in employee file. C. Hepatitis A and B Vaccine:. Hepatitis B vaccinations, Varicella vaccination, and annual tuberculosis testing. All newly admitted students are required to complete the Admission Health ... Southern Nevada; as accepted and voted on by the Medical Executive Committeeinfluenza vaccination or signed declination form in the last 12 months);. A brief informational summary and does not contain the complete text ofwith hepatitis B vaccine, at no charge to me; however, I decline hepatitis B. 4 Receive a presentation and review and recommend for approval by the. Board of County Commissioners also sitting as the Board of Hospital.