The University of Texas at Tyler
HEPATITIS B VACCINATION CONSENT OR DECLINATION FORM
Full Name:
UTT EID: Date of Birth:
I understand that due to my potential occupational exposure to blood or other potentially
infectious materials (OPIM), 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 OPIM and I want to be
vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to myself.
I understand that due to my potential occupational exposure to blood or OPIM, I may be at
risk of acquiring 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 because I have previously received the entire series of vaccinations. I
understand that by declining this vaccine, I release The University of Texas at Tyler from any
liability related to the inadequacy of my previous vaccination. If, in the future, I continue to
have occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis B
vaccine, I can receive the vaccination series at no charge to myself.
I consent to be immunized for the Hepatitis B vaccination (HBV) series. A new
consent form will be completed for each injection in the series.
I have been offered the opportunity for Hepatitis B surface antibody testing.
I
accept / decline to have my blood tested at no cost to me 1-2 months following
completion of the HBV vaccine series to determine immunity. A positive result indicates
immunity and a negative result indicates no immunity. If negative, a second 3 dose series will
be offered to me and I may be retested. If I remain negative after a second 3 dose series, I
will be referred for a medical evaluation.
I understand and/or have been informed about the following:
1. I received or was offered the HBV Vaccination Information Sheet (VIS) which lists the indications,
benefits, presently known side effects and adverse reactions of receiving the HBV vaccine.
2. I have been given the opportunity to ask questions regarding the virus, the vaccine, and my
potential occupational exposure.
3. I understand there is the potential for localized non-serious side effects such as swelling, redness
or soreness which is generally self-limiting and requires no treatment.
4. I understand there is no guarantee that I will not experience an adverse reaction or side effect
from the HBV vaccine or antibody testing procedure.
5. I have never had a serious allergic reaction or other problem to baker’s yeast or after receiving
doses of HBV in the past.
6. I am not currently pregnant. (HBV may be administered during pregnancy with physician
authorization.)
7. I am not currently ill.
Signature _____________________________________________ Date __________________
