Fillable Hepatitis B Vaccination Consent - Waiver Form

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Hepatitis B Vaccination Consent - Waiver Form

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Hepatitis B Vaccination Consent / Waiver Form
Department of Safety and Environmental Management
Created: 9/16/19
Revision: Revision #1 1 | Page
Medical consultation and the Hepatitis B vaccine series are made available to all employees who can reasonably
anticipate in coming into contact with human blood or other potentially infectious materials (OPIM) during their
normal duties. The vaccination series and medical consultation are offered at no cost to the employee once they
have completed the Bloodborne Pathogens training and had an opportunity to ask questions. Complete the form
below and choose the option that best fits your needs.
Name:
Date:
Department:
Job Title:
Signature:
Accept to Receive the Hepatitis B Vaccination Series. I understand that due to my potential occupational
exposure to human blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus.
I choose to accept medical consultation and Hepatitis B vaccine series offered by the City’s Occupational
Healthcare Provider at no charge to me.
I do not wish to receive the Hepatitis B Vaccination Series. I understand that due to my potential
occupational exposure to human blood or other potentially infectious materials (OPIM), I may be at risk of
acquiring Hepatitis B virus. I have been given the opportunity to receive medical consultation and be vaccinated
with Hepatitis B vaccine, at no charge to myself. However, I decline the medical consultation and 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 occupational exposure to blood or OPIM and I want to be
vaccinated with the Hepatitis B vaccine, I can receive the vaccination series and medical consultation at no
charge to me.
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Hepatitis B Vaccination Consent - Waiver Form

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Completed 11 July 2020

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