FCDS Hepatitis B Vaccine Employee Form

HEPATITIS B VACCINE

EMPLOYEE DECLINATION/REQUEST FORM

I understand that due to my occupational exposure to blood or other potentially infectious materials, I am at risk of acquiring Hepatitis B (HBV) Infection. I have been given the opportunity to be vaccinated with the Hepatitis B Vaccine Series at no cost to me.

Check ONE of the following:

I. DECLINE VACCINE SERIES

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I decline the Hepatitis B Vaccine Series 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 and want to be vaccinated with the Hepatitis B Vaccine, I can do so at no cost to me.

II. REQUEST VACCINE SERIES

_____	I request that I be provided the Hepatitis B Vaccination Series by my employer at no cost to me.
_____
_____	I request that I be provided the Hepatitis B Vaccination series by my employer at no cost to me. However, because of personal medical conditions, I prefer to check with my personal physician before receiving the vaccine. I realize that I am personally responsible for any fees my physician may charge me for this evaluation.

PLEASE PRINT

Name__________________________________________________________________

Social Security Number________________________________________________

Job Classification______________________________________________________

Date___________________________________________________________________

Signature______________________________________________________________