ATTACHMENT E
Hepatitis B vaccination Decline to Accept Form
DECLINE TO ACCEPT HEPATITIS B VACCINE
I have read
the information provided by the University Medical Center about
Hepatitis B and the Hepatitis B Vaccine, "Engerix-B". I have had an opportunity to ask questions,
understand the benefits and risks of the Hepatitis B Vaccine, and do not wish
to receive this vaccine. I request that
it not be given to me.
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.
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Signature of the Recipient
Date
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Signature of the Witness
Date
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Signature of Parent
(for minor students under age 19)