"VACCINATION DECLINATION FORM"
PLEASE PRINT/SIGN & BRING TO 1ST DAY OF CLASS CENTRAL CAROLINA COMMUNITY COLLEGE CHATHAM COUNTY NURSE AIDE II VACCINATION DECLINATION FORM STUDENT: LAST 4 Digits Social Security Number: I understand that due to my potential exposure to blood or other potential infectious materials during my Nurse Aide II clinical, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given information regarding the virus and the vaccine; however, I DO decline the vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. If I desire to receive the vaccination later, I may do so at my own discretion and my own expense. ______________________________ _____________________ Student Signature Date ______________________________ ______________________ Instructor Signature Date