The University of Louisiana at Monroe

 

Bloodborne Pathogens

Hepatitis B Vaccination Declination Statement

 

 

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 B vaccine, at no charge to myself. However, I decline hepatitis B vaccination 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.

 

 

 

 

 

 

Employee Name (Print)

 

 

ULM Representative Name (Print)

 

 

 

 

 

 

 

Employee Signature

 

 

ULM Representative Signature

 

 

 

 

 

 

 

Job Title

 

 

Job Title

 

 

 

 

 

 

 

Date

 

 

Date