Volunteer State Community College
Hepatitis B Immunization
Health History Form
ALL NEW STUDENTS ARE REQUIRED TO FILL OUT AND RETURN THIS FORM
HOWEVER, THE IMMUNIZATION ITSELF IS NOT REQUIRED
Name: ______________________________ ___________________ ____
Last First MI
Date of Birth: ____________ Student ID Number: ______________________ Phone: (______) ____________
Month/Day/Year
The General Assembly of the State of Tennessee mandates that each public or private postsecondary institution in the state provide
information concerning hepatitis B infection to all students matriculating for the first time. Tennessee law requires that such students
complete and sign a waiver form provided by the institution that includes detailed information about the disease. The required
information below includes the risk factors and dangers of the disease as well as information on the availability and effectiveness of
the vaccine for persons who are at-risk for the disease. The information concerning this disease is from the Centers for Disease
Control and the American College Health Association.
The law does not require that students receive vaccination for enrollment. Furthermore, the institution is not required by law
to provide vaccination and/or reimbursement for the vaccine.
A. Hepatitis B (HBV)
[TO BE COMPLETED BY ALL NEW STUDENTS]
Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver
failure, and even death. The disease is transmitted by blood and or body fluids and many people will have no symptoms
when they develop he disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease
is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series
of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if
only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in
most cases.
I hereby certify that I have read this information and I have receive d the complete three dose series of the
Hepatitis B vaccine.
Date of completion of the Hepatitis B vaccination series: ________/__________/_______
I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine.
I hereby certify that I have read this information and I have elected to receive the Hepatitis B vaccine and/or I am
in the process of receiving the complete three dose series of the Hepatitis B vaccine.
Signature of Student or Parent/Guardian (If student is under18):________________________________________Date:_________
For more information about the Hepatitis B disease and its vaccine, please contact your local health care provider or consult the
Center for Disease Control and Prevention Web site at http://www.cdc.gov/health/default.htm.
The completed and signed form can be faxed to 615-230-4875
or scanned and emailed to admissions@volstate.edu.
