Hepatitis B Declination Form

1. Name *This question is required.

First and Last

2. Date *This question is required.

3. Net ID *This question is required.

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 have chosen to decline the hepatitis B vaccination. 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.

4. I have read the application information, agree to the above terms and conditions, and verify that all above information is correct and current.

5. Signature

Clear

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