Office of Environmental, Health, Safety & Hazardous Waste

HEPATITIS B VACCINE DECLINATION FORM

I understand that due to my occupational exposure to blood or other infectious materials that I may be at risk of acquiring Hepatitis B virus infection.  I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself.  However, I decline the Hepatitis B vaccination at this time.  I understand that my 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 the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

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