Hepatitis B Immunization Consent/Waiver Form

Environmental Health and Safety
egregory@brockport.edu

Name - Employee Name - Employee First Last
Email - Employee
Job Title - Employee
By signing below, I am affirming that 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 received training relative to this, and have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself.
Indicate your choice:

Indicate your choice: Yes, I want to receive the Hepatitis B vaccine.
We will contact you within 5 days to make arrangements for your Hepatitis B vaccine. No, I do not wish to receive the Hepatitis B vaccine.
I decline the Hepatitis B vaccination at this time. I understand that by declining the 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 can receive the vaccination series at no charge to me. I would like to have immunity testing performed in order to guide my decision.
This is a blood test, we will contact you within 5 days to make arrangements for this.
Type your name as a legal representation of your signature:
Date Date / MM / DD YYYY
Name - Supervisor Name - Supervisor First Last
Privacy statement:
The College at Brockport understands that information is sensitive in nature. This, like all personal or medical information, will be treated with privacy and discretion. Copies of your medical records will solely exist in the EHS department, inside a secured filing cabinet. These records will be maintained for 30 years post‐separation, as required by federal law.