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Appendix A - Informed Consent/Decline for Hepatitis B Vaccination - Bloodborne Pathogen Policy

Appendix A - Informed Consent/Decline for Hepatitis B Vaccination

I, the undersigned employee, have read information about Hepatitis B and the Hepatitis B 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 in the workplace. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself.

I further understand the risks involved in making this decision and I agree that MSAD #35, its agents and employees, who are required by law or regulation to make the Hepatitis B Vaccine available to me, are not legally responsible or liable for the side effects that may occur as a result of my accepting/not accepting the Hepatitis B Vaccine.

_____ I have opted to decline the Hepatitis B Vaccine at this time, I have already had the Hepatitis B Vaccine.

_____ I agree to accept the Hepatitis B Vaccine, given in three (3) doses over the next 6 months. (If you are pregnant or breastfeeding, it is advisable that you consult with your doctor before taking the Hepatitis B series/)

_____ I have opted to decline the Hepatitis B Vaccine 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.


Print Name: ______________________________ Title: ____________________

Signature:   ______________________________ Date: ____________________

School:   ________________________________________________________

Witness: ______________________________ Date: _____________________

Hepatitis B Virus/Vaccine


For Your Information - Please Read Carefully


The Disease - Hepatitis B is a viral infection caused by the Hepatitis B virus which causes death in 1% to 2% of patients infected. Most people with Hepatitis B recover completely but approximately 5% to 10% become chronic carriers of the virus. Most of these people have no symptoms but can continue to transmit the disease to others. Some may develop chronic hepatitis or cirrhosis. Carriers also run a high risk of developing primary liver cancer and pregnant carriers transmit the HBV through the placenta with some 90% of infected infants becoming carriers.


Simple, Effective Solution - Fortunately, now, there is a simple way to prevent HBV infection. The Center for Disease Control (CDC) recommends vaccination for anyone frequently exposed to blood or other body fluids in the workplace. Your individual risk is directly related to how often you are exposed to blood and other body fluids.


The Vaccine - The Hepatitis B Vaccine currently used is a noninfectious vaccine made from bread yeast (Saccharomyces cerevisiae). When injected into the deltoid muscle, the hepatitis vaccine has induced protection levels of antibody in more than 90% of the healthy individuals who received the recommended three doses of the vaccine. Persons with immune-system abnormalities have less response to the vaccine. Full immunization requires three doses of vaccine over a six month period. There is no evidence that the vaccine has ever caused Hepatitis B. However, persons who have been infected with Hepatitis B virus prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization. The duration of immunity is unknown at this time.


Possible Adverse Side Effects - the incidence of side effects is very low. No serious side effects have been reported with the vaccine. Some people have experienced:


  • Soreness, swelling, warmth, itching, redness, bruising and nodule formation at the injection site
  • Fever ^100 degrees F and malaise
  • Tiredness/weakness
  • Headache
  • Nausea and/or diarrhea
  • Sore throat and/or upper respiratory infection
  • Dizziness
  • Muscle aches
  • Joint pain