Hepatitis B Virus Vaccine

HEPATITIS B VIRUS VACCINE

EXCEPTION/CONSENT WAIVER

HEPATITS B VIRUS/VACCINE INFORMATION ACKNOWLEDGEMENT

(Each employee Must Read and Sign This Section)

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PRINT NAME

I have read the Fact Sheet about hepatitis B and the hepatitis B vaccine. I have also read the brochure provided and had an opportunity to have all my questions answered. I certify that I understand the benefits and risk of Hepatitis B vaccination and the benefits and risk of not having the vaccination. I understand I must have all three doses of the vaccine to confer immunity. However, as with all medicine treatment there is no guarantee that I will become immune, that the vaccine will prevent me from developing Hepatitis B, or that I will not experience adverse side effects from the vaccine. I understand this is a voluntary vaccination.

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SIGNATURE (Required by all employees)DATE

(Each employee must complete one of the following sections)

HBV VACCINE EXCEPTION

I understand that due to my occupational exposure to blood and other potentially infectious materials, I maybe 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 the Hepatitis B vaccination at this time due to one of the following reasons;

_____ I have received a hepatitis B vaccination previous to my employment with NursesPro

______I am immune to the hepatitis B virus infection

______My current medical condition does not allow me to be vaccinated at this time.

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EMPLOYEE SIGNATUREDATE

HBV VACCINE CONSENT

I consent to administration of the hepatitis B vaccine. I have been informed of the method of administration, their risks of complications, and excepted benefits of the vaccine.

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EMPLOYEE SIGNATUREDATE

HBV VACCINE WAIVER

I understand that due to my occupational exposure to blood or other potentially infectious materials, I maybe 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; I have been provided a brochure and a fact sheet on hepatitis B and the vaccination.

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 infections materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccinations series at no charge to me.

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EMPLOYEE SIGNATUREDATE