* = Required Information
I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring the Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the vaccine, at no charge to me.

HOWEVER, I DECLINE THAT 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 want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

I DECLINE BECAUSE I ALREADY RECEIVED THE VACCINE.

Employee Signature* Date
BY SIGNING MY NAME ABOVE, I AM STATING THAT I DO WISH TO HAVE THE HEPATITIS B VACCINE. I UNDERSTAND THAT THIS IS A SERIES OF THREE (3) INJECTIONS AND THAT I MUST RECEIVE ALL INJECTIONS TO BE CONSIDERED VACCINATED AGAINST HBV INFECTION.

 
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