MSU Hepatitis A 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 occupational exposure to potentially infectious materials that may contain a risk of acquiring a hepatitis A virus (HAV) infection. I have been given the opportunity to be vaccinated with hepatitis A vaccine, at no charge to myself. However, I decline hepatitis A vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis A, a serious disease. If in the future I continue to have occupational exposure to potentially infectious materials and I want to be vaccinated with hepatitis A 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

Signature of