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Hepatitis B Vaccine Declination (Mandatory) 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. Date Signature Printed Name S.S. number _________________________ Department ___________________________ Witness ______________________________________________________________________________ For office use only ___________________ Does this employee have: 1). Natural antibodies? 2). Previous successful HBV immunization? 3). Medical contraindication to immunization? If the answer to any question is yes, provide documentation. Send this form to the Center for Environmental Health and Safety Attachment 1, OECP, SIUC Jan. 1994.
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