HEPATITIS VACCINE REQUIREMENT

HEPATITIS VACCINE REQUIREMENT
I, , acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B because of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself. It is my decision to:
Request that I receive the Hepatitis vaccineRefuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the 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 vaccine series at no charge to me.Provide written proof of immunity (attach)Provide written proof of previous vaccination (attach)Provide written proof of medical contraindication (attach)
Provide written proof of immunity (attach)

Cancelof
Provide written proof of previous vaccination (attach)

Cancelof
Provide written proof of medical contraindication (attach)

Cancelof
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