Fillable Form 2: What You Need to Know 1 (Wright State University)

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Form 2: What You Need to Know 1 (Wright State University)

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VACCINE INFORMATION STATEMENT
Many Vaccine Information Statements are
available in Spanish and other languages.
See www.immunize.org/vis
Hojas de información sobre vacunas están
disponibles en español y en muchos otros
idiomas. Visite www.immunize.org/vis
U.S. Department of
Health and Human Service
s
Centers for Disease
Control and Prevention
Hepatitis B Vaccine:
What You Need to Know
1
Why get vaccinated?
HepatitisB vaccine can prevent hepatitisB.
HepatitisB is a liver disease that can cause mild
illness lasting a few weeks, or it can lead to a serious,
lifelong illness.
Acute hepatitisB infection is a short-term illness
that can lead to fever, fatigue, loss of appetite,
nausea, vomiting, jaundice (yellow skin or eyes,
dark urine, clay-colored bowel movements), and
pain in the muscles, joints, and stomach.
Chronic hepatitisB infection is a long-term
illness that occurs when the hepatitisB virus
remains in a person’s body. Most people who go
on to develop chronic hepatitisB do not have
symptoms, but it is still very serious and can lead
to liver damage (cirrhosis), liver cancer, and death.
Chronically-infected people can spread hepatitisB
virus to others, even if they do not feel or look sick
themselves.
HepatitisB is spread when blood, semen, or other
body uid infected with the hepatitisB virus enters
the body of a person who is not infected. People can
become infected through:
Birth (if a mother has hepatitisB, her baby can
become infected)
Sharing items such as razors or toothbrushes with
an infected person
Contact with the blood or open sores of an infected
person
Sex with an infected partner
Sharing needles, syringes, or other drug-injection
equipment
Exposure to blood from needlesticks or other sharp
instruments
Most people who are vaccinated with hepatitisB
vaccine are immune for life.
2
Hepatitis B vaccine
HepatitisB vaccine is usually given as 2, 3, or 4 shots.
Infants should get their rst dose of hepatitisB
vaccine at birth and will usually complete the series
at 6 months of age (sometimes it will take longer
than 6 months to complete the series).
Children and adolescents younger than 19 years of
age who have not yet gotten the vaccine should also
be vaccinated.
HepatitisB vaccine is also recommended for certain
unvaccinated adults:
People whose sex partners have hepatitisB
Sexually active persons who are not in a long-term
monogamous relationship
Persons seeking evaluation or treatment for a
sexually transmitted disease
Men who have sexual contact with other men
People who share needles, syringes, or other drug-
injection equipment
People who have household contact with someone
infected with the hepatitisB virus
Health care and public safety workers at risk for
exposure to blood or body uids
Residents and sta of facilities for developmentally
disabled persons
Persons in correctional facilities
Victims of sexual assault or abuse
Travelers to regions with increased rates of
hepatitisB
People with chronic liver disease, kidney disease,
HIV infection, infection with hepatitis C, or
diabetes
Anyone who wants to be protected from hepatitisB
HepatitisB vaccine may be given at the same time as
other vaccines.
Office use only
3
Talk with your health care
provider
Tell your vaccine provider if the person getting the
vaccine:
Has had an allergic reaction aer a previous dose
of hepatitisB vaccine, or has any severe, life-
threatening allergies.
In some cases, your health care provider may decide
to postpone hepatitisB vaccination to a future visit.
People with minor illnesses, such as a cold, may be
vaccinated. People who are moderately or severely ill
should usually wait until they recover before getting
hepatitisB vaccine.
Your health care provider can give you more
information.
4
Risks of a vaccine reaction
Soreness where the shot is given or fever can
happen aer hepatitisB vaccine.
People sometimes faint aer medical procedures,
including vaccination. Tell your provider if you feel
dizzy or have vision changes or ringing in the ears.
As with any medicine, there is a very remote chance
of a vaccine causing a severe allergic reaction, other
serious injury, or death.
5
What if there is a serious
problem?
An allergic reaction could occur aer the vaccinated
person leaves the clinic. If you see signs of a
severe allergic reaction (hives, swelling of the face
and throat, diculty breathing, a fast heartbeat,
dizziness, or weakness), call 9-1-1 and get the person
to the nearest hospital.
For other signs that concern you, call your health
care provider.
Adverse reactions should be reported to the Vaccine
Adverse Event Reporting System (VAERS). Your
health care provider will usually le this report, or
you can do it yourself. Visit the VAERS website at
www.vaers.hhs.gov or call 1-800-822-7967. VAERS
is only for reporting reactions, and VAERS sta do not
give medical advice.
6
The National Vaccine Injury
Compensation Program
e National Vaccine Injury Compensation
Program (VICP) is a federal program that was
created to compensate people who may have been
injured by certain vaccines. Visit the VICP website
at www.hrsa.gov/vaccinecompensation or call
1-800-338-2382 to learn about the program and
about ling a claim. ere is a time limit to le a
claim for compensation.
7
How can I learn more?
Ask your healthcare provider.
Call your local or state health department.
Contact the Centers for Disease Control and
Prevention (CDC):
- Call 1-800-232-4636 (1-800-CDC-INFO) or
- Visit CDC’s www.cdc.gov/vaccines
8/15/2019 | 42 U.S.C. § 300aa-26
Vaccine Information Statement (Interim)
Hepatitis B Vaccine
Department of Environmental Health and Safety
3640 Colonel Glenn Hwy
Biological Sciences 2 | Rm. 047
Dayton, OH 45435
937-775-2215 | www.wright.edu/ehs | ehs@wright.edu
Printed Name
HEPATITIS B VACCINE ACCEPT/DECLINE FORM
STUDENT
FACULTY
STAFF
STUDENT EMPLOYEE
Department Supervisor/Lab Supervisor (print)
Department Phone Your Email Address
DECLINATION
I decline, at this me, to receive the Hepas B Vaccine Series.
I un
derstand that due to my occupaonal exposure to blood or other potenally infecous materials I may be at risk of acquiring
hepas B virus (HBV) infecon. I have been given the opportunity to be vaccinated with the hepas-B vaccine, at no charge to
myself. However, I decline hepas B vaccinaon at this me. I understand that by declining this vaccine, I connue to be at risk of
acquiring hepas B, a serious disease. If in the future I connue to have occupaonal exposure to blood or other potenally
infecous materials and I want to be vaccinated with hepas B vaccine, I can receive the vaccinaon series at no charge to me.
CONSENT
I consent to receive the Hepas B Vaccine Series and have been counseled by a licensed health care
provider. I understand that this vaccinaon is oered at no charge to myself, but I am required to complete the
enre 3 shot series to be fully vaccinated.
See instrucons on reverse side.
PREVIOUSLY COMPLETED
I previously completed the Hepatitis B Vaccine Series.
A copy of past vaccination records MUST be submitted to Student Health Services. Call 937-245-7200.
OFFICE USE ONLY
EHS APPROVAL: ____________________________________________ DATE: ______________________________
SHOT 1 SHOT 2 SHOT 3
DATE: LOT#
___________________ _____________________
DATE: LOT#
___________________ _____________________
DATE: LOT#
___________________ _____________________
PROVIDER SIGNATURE
__________________________________________
PROVIDER SIGNATURE
__________________________________________
PROVIDER SIGNATURE
__________________________________________
Signature Today’s Date
Return this form to Environmental Health & Safety at the address or email at top of form.
SIGNATURE OF CONFIRMATION
OSHA HBV Form REV 10 2020 | Page 1 of 2
click to sign
signature
click to edit
Department of Environmental Health and Safety
3640 Colonel Glenn Hwy
Biological Sciences 2 | Rm. 047
Dayton, OH 45435
937-775-2215 | www.wright.edu/ehs
INSTRUCTIONS
You have requested to receive the Hepas B vaccine series as a parcipant in the University’s Bloodborne Pathogens
Program. There are three shots required in the vaccinaon series:
Shot 1
Shot 2 – One month later
Shot 3 – Six months later
Keep this form - You will take it with you each me you receive your vaccinaon series.
Wright State Physicians Health Center
Student Health Services
725 University Boulevard
Hours: M-F 8:30 to 11:30 am and 1:00 pm to 4:30 pm
Call in advance.
Department of Environmental Health and Safety
047 Biological Sciences II
937-775-4444 or 937-775-2215
Call in advance.
We will make a copy and return the original to you. Keep your original to be used each time you
receive your vaccination series.
Additional shots are required one month and six months in the future in the vaccination series.
If you decide not to complete the Hepatitis B vaccination series contact:
Department of Environmental Health and Safety
047 Biological Sciences II
937-775-2215 or 937-775-4444
email: ehs@wright.edu
STEP 1: TO RECEIVE YOUR VACCINATION TAKE THIS FORM TO
STEP 2: AFTER EACH SHOT RETURN THIS FORM TO
CHANGE YOUR MIND?
OSHA HBV Form REV 10 2020 | Page 2 of 2
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Completed 16 December 2020

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