Hep B Declination Form Template Details

If you are a doctor who sees patients with hepatitis B, it is important to have a documentation form to keep track of the information related to these patients. The hepatitis B documentation form can help you keep track of the patient's medical history, current treatment, and any other information that is relevant to their care. Having this form can help ensure that your patients receive the best possible care.

This article has got information about hepatitis b documentation form. Before you decide to complete the form, it is usually definitely worth learning more details on it.

QuestionAnswer
Form NameHepatitis B Documentation Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshepatitis b declination, hepatitis b vaccine documentation form, hepatitis b acceptance declination page, vaccine acceptance form

Form Preview Example

HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM

ACCEPTANCE:

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV). This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B (HBV) vaccine.

DECLINATION:

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.

CHECK ONE:

_____ I ACCEPT Hepatitis B vaccine inoculation: OR

_____ I DECLINE Hepatitis B vaccine inoculation.

____________________________

Employee's Name

____________________________

_______________

Employee's Signature

Date

____________________________

_______________

Witness Signature

Date

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