Hepatitis B Vaccine Acceptance or Declination HEPATITIS B VACCINE CONSENT _____ (initial) I consent to the administration of the hepatitis B vaccine. I have been informed of the method of administration, the risks, complications, and expected benefit of the vaccine. I understand that the facility is not responsible for any reactions caused by the vaccine. I understand that the hepatitis B vaccine is available, at no cost, to employees whose job duties involve the risk of direct exposure to blood or other potentially infections material. I understand that the vaccine series will be administered according to recommendations for standard medical practice in the community. I have been informed that my first series of the vaccine will be available to me within 10 days of my initial assignment of duty in a reasonable time and place and by a licensed healthcare professional. I have been informed that the facility will continue to offer at no charge to myself the additional series during my employment. I will be responsible for reporting to the licensed nurse on the scheduled dates for these injections. I have been informed that if I have previously received the complete hepatitis B vaccine series, have antibody testing conducted that reveals my immunity, or the vaccine is contraindicated for medical reasons; I will not be offered the vaccine. I have been informed that if a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, it will be made available to me in accordance with OSHA regulations. I have been informed that if I am eligible, I may be tested to determine the efficacy of the vaccine at no cost to me. Please complete the information below, to the best of your ability. _____ (initial) I have had 1 dose of vaccination prior to my present employment. Date administered: ______________________ (or) _____ (initial) I have had 2 doses of vaccination prior to my present employment. Date administered: ______________________ HEPATITIS B VACCINE DECLINATION _____ (initial) 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 the hepatitis B vaccine at this time. 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 risk of occupational exposure to blood or other potentially infectious material and want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination series at no charge to me. _____ (initial) I have had the hepatitis B series (all 3 injections) prior to my present employment. Date administered: ______________________
Employee Signature
Date
Printed Name Dose #1: ______________________________________ Manufacturer Name, Lot #, Expiration Date
_________________________________ Administered by
Date
Dose #2: ______________________________________
_________________________________
Manufacturer Name, Lot #, Expiration Date (To be administered 30 days after first vaccine)
Administered by
Dose #3: ______________________________________
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Manufacturer Name, Lot #, Expiration Date (To be administered 150 days after the 2nd dose)
Administered by
Date
Date
