Title:Hepatitis B Vaccine Declination Form

Title:Hepatitis B Vaccine Declination Form

Document Number: OH-FRM-003

Revision: New

Date Approved: 12/15/2010

1.0 Purpose: The purpose of this form is to provide written declination of the series of vaccinations of the Hepatitis B vaccine as prescribed by the University of Wisconsin Exposure Control Plan for Bloodborne Pathogens. This completed form is legal documentation regarding a bloodborne pathogen workers declination of this vaccine series.

2.0  Directions: Read the contents of the University of Wisconsin-Madison Informed Consent For Hepatitis B Vaccine document prior to the individual’s determination on whether to decline or receive the vaccination. If the individual would like to decline the series of vaccinations then they must completely fill out this form.

I (print name) _ have read the information provided by UW-Madison Occupational Health Program about hepatitis B and hepatitis B vaccine. I have had the opportunity to ask questions about the vaccine. I understand the following: 1) benefits and risks of hepatitis B immunization; 2) a minimum of three doses of hepatitis B vaccine are recommended for the vaccine to be fully effective; 3) there is no guarantee that a person immunized will become immune; and 4) side effects may be experienced from the vaccine.

______

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 materials and I want to be vaccinated with Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.

OR

I have already received the Hepatitis B vaccination series and do not require vaccination.

JOB TITLE ______

DEPT.______

Birthdate ______

Phone #______Email______

Signature ______Date ______

-Please keep a copy of this form for your records. Send a copy of this form to the UW Madison Environment, Health and Safety Department - Occupational Health Program, 30 East Campus Mall.

Printed Date: 8/14/2016 Page 1 of 1