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Hepatitis B Vaccine Declination Form
State University of New York at Geneseo
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 material and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Employee Signature: Date:
Witness Signature: Date:
The original of this form is to be maintained by the Human Resources Department.