HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM

I understand that due to my occupational exposure to blood or other potentially infectious materials that 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. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I received, I am making an informed decision to accept the Hepatitis B (HBV) vaccine.

I understand that due to my occupational exposure to blood or other poten tially infectious materials that 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. 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 andI

want to be vaccinated with Hepatitis B vaccine, I can do so at any time.