Employee Hepatitis B Declaration Form

I have received information and training pertaining to hepatitis Band the vaccine. I have had the opportunity to ask questions, and they have been answered to my satisfaction. I understand the benefits and risk of the vaccine and I consent to receive this vaccine. I understand that I am responsible for scheduling and keeping my appointments to receive the hepatitis B vaccine in accordance with the recommended series (three-dose vaccination series; 0, 1 and 6 months apart).

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 me; 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 to me.