Hepatitis B Declination Form

Employee Name: ___________________________ Date of Birth: ______________________________

Job Title:

understand that due to the possibility for occupational
exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis virus
(HBV) infection. I have been given the opportunity to receive the Hepatitis B vaccine, at no charge to
myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this
vaccine, I may continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I want to
be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Employee Name (print):

Employee Signature:

Supervisor Name (print):

Supervisor Signature: