HEPATITIS INFORMATION ACKNOWLEDGEMENTACCEPT OR DECLINATION STATEMENT
I have read and understand the information in the Hep-B packet. My signature below indicates acknowledgment of this information and my decision to either accept or decline the Hepatitis B vaccination.
If I accept the vaccination, I understand that I will be given the opportunity to participate in the series, which includes injections at 0, 30, and 180 day intervals. I will comply with the administration procedure, and am aware of the adverse effects, contraindications, and complications that may occur due to the Hepatitis B Vaccination.
If I decline the vaccination, I either have received the vaccination prior, OR 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 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
I WANT TO PARTICIPATE IN THE HEP-B PROGRAM
* I DON'T WANT TO PARTICIPATE IN THE HEP-B PROGRAM