404.3E3 HEPATITIS B VACCINE INFORMATION AND RECORD

RELEASE FORM FOR HEPATITIS B MEDICAL INFORMATION

 

I hereby authorize _________________________ (individual or organization holding Hepatitis B records and address) to release to the Red Oak Community School District, my Hepatitis B vaccination records for required employee records.

I hereby authorize release of my Hepatitis B status to a health care provider, in the event of an exposure incident.

________________________________________                      ___________________

Signature of Employee                                                                                   Date

 

________________________________________                      ___________________

Signature of Witness                                                                                      Date