Hepatitis B vaccination Consent

Hepatitis B Vaccination Consent Form
I understand the benefits and risks of hepatitis B vaccination. I understand that I must receive at least 3 intramuscular doses of vaccine in the arm over a 6-month period to confer immunity. However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side effect from the vaccine.

I do understand that anyone with a known allergy to yeast should not accept this vaccine. Hepatitis B vaccine will be made available at no charge to employees having occupational blood exposure.

I have had an opportunity to ask questions, and all my questions have been answered to my satisfaction.

I believe that I have adequate upon which to base an informed consent. I understand that participation is voluntary, and my consent or refusal of vaccination does not waive any rights under my employment contracts. In addition, I can withdraw from the vaccination regimen at any time.

I desire that my employer provide the required three (3) doses of Hepatitis B Vaccine.
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Hepatitis B Vaccination Declination From

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 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 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
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If applicable, fill out the following information:
I have received the Hepatitis B vaccination on:

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Date

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Hepatitis B Vaccination Consent Form

Hepatitis B Vaccination Declination From

If applicable, fill out the following information: