TANNEHILL

HEPATITIS B VACCINE CONSENT/REFUSAL FORM

Employee's Name ___________________________________________________________  Date:___________

Social Security No. ______________________________ Position:_____________________________________

I understand that Hepatitis B is a serious disease that can lead to a chronic form of hepatitis, which may even­tually result in death.  I understand that I may be at increased risk for contracting the disease by the very nature of my job.  Should I contract the disease, I could be potentially infectious, thereby exposing individ­uals with whom I may have intimate contact (including dental, sexual, to my unborn child should pregnancy occur, etc.).

I understand that although there are risks associated with taking the Hepatitis B vaccine, it does reduce the risk of serious disease should exposure to the Hepatitis B virus occur.

I further understand my decision to take or decline Hepatitis B vaccine will not adversely affect my employment or any benefits available to me through my employment.

_____  I hereby elect to receive the Hepatitis B vaccine series provided to me free of charge by the Tannehill School District and hereby agree to hold the Tannehill School District harmless for any reaction or side effect I may experience from the vaccine.

_____  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 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.

_____________________________________________________          ________________________________

Employee's Signature                                                                                     Supervisor's Signature

Vaccine _______________________________ Manufacturer ________________________________________

                    Date                                 Site                                      Lot #                                   Given By

   1.       ____________________________________________________________________________________

   2.       ____________________________________________________________________________________

   3.       ____________________________________________________________________________________

   4.       ____________________________________________________________________________________

Repeat Anti-HB's _______________________________________     Date______________________________

                                  _______________________________________     Date______________________________

                                  _______________________________________     Date______________________________

                                  _______________________________________     Date______________________________

                                  _______________________________________     Date______________________________

                                  _______________________________________     Date______________________________