Hepatitis B DeclinationInformed refusal of Hepatitis B Vaccination(Declination Form) I, * employed by * As a RN/LPN have received training regarding the Hepatitis B Vaccine. I understand that due to my occupational exposure of blood and other potentially infectious materials I may be at risk of acquiring Hepatitis B (HBV) infection. If I need the Hepatitis B Vaccination series, I understand that this will be an expense that I am responsible to cover. However, currently I am declining this vaccine and by declining this vaccine I understand that I continue to be at risk of acquiring Hepatitis B, a serious disease. Signature * Name * Your Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer * Today's Date * MM DD YYYY Check One: I am signing this declination form because I have already been vaccinated but do not have a copy of a vaccination certificate for my medical records. Prior to employment with this organization my blood was tested and I was advised that I have adequate HBV antibodies. Re-vaccination is not required. Prior to employment with this organization my blood was tested and I was advised that I am a non-responder. I was never re-vaccinated following the initial test. I would like to be vaccinated and understand the expense of this vaccination is not covered by Haggai Healthcare. Prior to employment with this organization my blood was tested and I was advised that I am a non-responder. I was never re-vaccinated following the initial test. I do not wish to be vaccinated at this time. Signature * Name * Thank you!
