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: ____________________________________________________________
Series Date Administered By Lot # Expiration Date