I acknowledge that I am at risk of exposure or have been unknowingly exposed to the Hepatitis B
virus as a result of my employment and acknowledge that I will like to receive the Hepatitis B
Vaccine. It is my decision to request that I receive the Hepatitis B Vaccine.
II. Declination of Hepatitis B Vaccine
I am refusing the Hepatitis B Vaccine and hold harmless the Agency. 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
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 want to be vaccinated
with the Hepatitis B Vaccine, I may receive the Hepatitis B Vaccination Series at no charge to me
from Raffa Home Care.
III. Documentation of Hepatitis B Vaccine Series
If you have received the complete Hepatitis B Vaccine Series, you must attach to this form the
documentation, which proves your receipt of the HBV Series and the titer results indicating your
immunity. If you are unable to receive the vaccination series for medical reasons please attach
Your information will be encrypted.
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