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: _____________________