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Due to your occupational exposure to blood or other potentially infectious materials, you may be at risk for acquiring hepatitis B viral (HBV) infection. The vaccination series is available, at no cost to you. Please indicate below your declination or acceptance to receive the vaccine. Hepatitis B is a blood born virus which can cause a range o symptoms from mild to serious, and possibly result in fatal liver damage to health care workers who become infected. The virus can be transmitted through contact with infectious fluids of a patient who has the hepatitis B virus. You have been taught the concept of Universal Precautions concerning safe patient care and the use of equipment to avoid unnecessary exposure. The synthetic hepatitis B vaccines is derived from yeast cells. It is not composed of human blood or plasma. It is given as a series of three injections into the arm muscle at prescribed intervals (initial shot, one month later, and six months later) It has proven to be over 80-90% effective in protecting against the disease. There may be hypersensitivity to the vaccine, and there may be soreness and swelling of the injection arm. Other side effects may occur at an incidence of fewer than 3% of injections. The vaccine will not be given to persons with known sensitivity to aluminum hydroxide, thimerosal, and yeast or hepatitis antigen and will only be given with your personal physician's recommendations in cases of pregnancy or presence of other infection of immunosuppressive state. The vaccine does not grant 100% assurance of immunity.
*please choose an option below Acceptance: I have read the above information describing the risks and benefits of receiving the vaccination. I understand that the decision to receive the vaccination series is mine and I wish to receive the hepatitis B vaccine.
Declination: I have been given the opportunity to be vaccinated with hepatitis B vaccine, at not charge to myself. I decline the vaccinator series. I understand that by declining this vaccine, I continue to be at risk for acquiring hepatitis B. If I continue to have occupational exposure to blood or other potentially infectious material (OPIM) and I want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination series at no charge to me. I have already received the vaccination series for Hepatitis B.
I have already received the vaccination series for Hepatitis B.
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