HEPATITIS B-VACCINATION EXEMPTION FORM AND DECLINATION FORM

							HEPATITIS B VACCINATION EXEMPTION FORM (MANDATORY)-ATTACHMENT 5
I hereby declare that I am exempt from the requirement of Hepatitis B vaccination because:

_____I have already received the complete Hepatitis B vaccination series (verification attached).
_____I have demonstrated immunity through antibody testing (verification attached).
_____The vaccine offers medical contraindications for me (verification attached).

Employee’s name: ______________________________ Campus: _______________________

Employee Identification # __________________ _______Position: _______________________

Employee’s Signature: ____________________________Date: _________________________




HEPATITIS B VACCINE DECLINATION FORM (MANDATORY)
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, if 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.

Date: _________________________________Campus: ________________________________

Employee Signature: ____________________________________________________________




HBV VACCINATION
______________________________________________________________________________
Series        Date          Administered By      Lot #         Expiration Date

______________________________________________________________________________
Vaccine #1
______________________________________________________________________________
Vaccine #2
______________________________________________________________________________
Vaccine #3