© 2015-2016 WORKS International, Inc. All rights reserved. CONFIDENTIAL
Hepatitis B Vaccination Consent / Waiver / Request Form
SECTION A: GENERAL INFORMATION
Check the box appropriate for your situation:
Your required follow-up action:
I have already received the Hepatitis B vaccine.
Complete only Section A, and give this form to your supervisor.
I do not work in a qualifying high-risk job classification,
and I do not wish to receive the Hepatitis B vaccine.
Complete only Section A, and give this form to your supervisor.
I do not work in a qualifying high-risk job classification,
but I do wish to receive the Hepatitis B vaccine.
Complete Section A and Section D, and give this form to your
supervisor.
I work in a qualifying high-risk job classification.
Complete Section A, plus Section B or Section C, and give this
form to your supervisor.
Employee Name (Print. Please include maiden name, if applicable.)
School and Department
Birth Date
Job Classification
Employee Signature
Date Signed
SECTION B: HEPATITIS B VACCINE CONSENT
I have read about Hepatitis B and the Hepatitis B vaccine in the Bloodborne Pathogens for School Employees course. I have had the
opportunity to speak with a qualified nurse, and I understand the benefits and risks associated with the vaccine. I also understand that I must
have three (3) doses of the Hepatitis B vaccine to obtain immunity. I realize that the vaccine does not guarantee immunity, and that it may
produce side effects.
Employee Signature
Date Signed
SECTION C: HEPATITIS B VACCINE WAIVER
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
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.
Employee Signature
Date Signed
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signature
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signature
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signature
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signature
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© 2015-2016 WORKS International, Inc. All rights reserved. CONFIDENTIAL
Hepatitis B Vaccination Consent / Waiver / Request Form
SECTION D: HEPATITIS B VACCINE REQUEST
Employee Name (Please print. Include maiden name, if applicable.)
Employee ID Number (If applicable.)
School and Department
Birth Date
Job Classification
Worksite Building
Worksite Room / Area
I do not work in a qualifying high-risk job classification, as defined by the school district’s Bloodborne Pathogens Program. However, I am
requesting a Hepatitis B vaccine because of the following special circumstances:
Employee Signature
Date Signed
District Administrative Review (To be filled out by an administrator or designee.)
Findings / Decision:
Administrator Signature Date
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signature
click to edit
click to sign
signature
click to edit
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