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 Name:                                                                                                         

 

Employee Signature:                                                                              Date:              

 

Job Title:                                                                                                                     

 

Witness Name:                                                                                                            

 

Witness Signature:                                                                                 Date:              

      

The original of this form is to be maintained by the Human Resources Department.