University at Albany, State University of New York


Hepatitis B Vaccination Declination Form

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 Vaccine, at no charge to myself. 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 an occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B Vaccine, I can receive the vaccination at no charge.

 

 

Signature:_______________________________________________

Print Name:______________________________________________

 

Date:____________________________________________________

 

 

Please return this form to the Environmental Health & Safety Office,

Chemistry B-73.

Any question, please call 442-3495 and ask for Michelle.

EH&S 1999/ R3