Hepatitis B Vaccine Acceptance/Declination Form at a glance
What it is: Hepatitis B vaccine acceptance/declination form, where the employee accepts or declines the Hepatitis B vaccine.
Who signs: Sign at Employee's Signature and enter the Date. The witness signs at Witness Signature and enters the Date.
A filled-in Hepatitis B Vaccine Acceptance/Declination Form example: an employee accepts the vaccine
How to fill out Hepatitis B Vaccine Acceptance/Declination Form, box by box
Check one: accept or decline
Check one: I ACCEPT Hepatitis B vaccine inoculation OR I DECLINE Hepatitis B vaccine inoculation.
Acceptance: due to your occupational exposure to blood or other potentially infectious materials, you may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV). You certify that you have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. You have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to you. Based on the training you have received, you are making an informed decision to accept the Hepatitis B (HBV) vaccine.
Declination: you decline Hepatitis B vaccination at this time, and you understand that by declining this vaccine, you continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future you continue to have occupational exposure to blood or other potentially infectious materials and you want to be vaccinated with Hepatitis B vaccine, you can receive the vaccination series at no charge to you.
Employee's name, signature and date
Write your name at Employee's Name.
Sign at Employee's Signature and enter the Date.
Witness signature and date
The witness signs at Witness Signature and enters the Date.
Sources
[1] Hepatitis B Vaccine Acceptance/Declination Form, served file (no issuer file) (the Official source link on this page).
