Hepatitis B Vaccine Consent/Refusal Form

Employee's Name ____________________________________________

Social Security No. ____________________________________________ Position: ____________________________________________

Date: ____________________________________________

I understand that Hepatitis B is a serious disease that can lead to a chronic form of hepatitis, which may eventually result in death. I understand that I may be at increased risk for contracting the disease by the very nature of my job. Should I contract the disease, I could be potentially infectious, thereby exposing individuals with whom I may have intimate contact (including dental, sexual, to my unborn child should pregnancy occur, etc.). I understand that although there are risks associated with taking the Hepatitis B vaccine, it does reduce the risk of serious disease should exposure to the Hepatitis B virus occur. I further understand my decision to take or decline Hepatitis B vaccine will not adversely affect my employment or any benefits available to me through my employment.

I hereby elect to receive the Hepatitis B vaccine series provided to me free of charge by the Oologah-Talala School District and hereby agree to hold the Oologah-Talala School District harmless for any reaction or side effect I may experience from the vaccine.

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.

Employee's Signature ____________________________________________

Supervisor's Signature ____________________________________________

Repeat Anti-HB's Date ____________________________________________

Date ____________________________________________

Date ____________________________________________

Date ____________________________________________

Date ____________________________________________

Date ____________________________________________