CONSENT FORM OF HEPATITIS B VACCINATION
I have knowledge of Hepatitis B and the Hepatitis B vaccination. I have had an opportunity to ask questions of a qualified nurse or physician and understand the benefits and risks of Hepatitis B vaccination. I understand that I must have three doses of the vaccine to obtain immunity. However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience side effects from the vaccine. I give my consent to be vaccinated for Hepatitis B.
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Signature of Employee (consent for Hepatitis B vaccination) Date
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Signature of Witness Date
REFUSAL FORM OF HEPATITIS B VACCINATION
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the Hepatitis B virus infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself. However, I decline the 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 the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
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Signature of Employee (refusal for Hepatitis B vaccination) Date
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Signature of Witness Date
I refuse because I believe I have (check one)
__________started the series __________completed the series
