Appendix A -
Informed Refusal For Hepatitis B Vaccination or Antibody Titer

 

 


 

Hepatitis B Vaccination

Consent or Declination Form 

I have received training on the dangers of blood borne pathogens.  I understand that my position with San Juan College may involve occupational exposure to blood or other potentially infectious materials and I may be at risk of acquiring Hepatitis B virus (HBV) infection if exposed. 

I have been given the opportunity to be vaccinated with Hepatitis B vaccine.  By accepting, I understand that the vaccination will be at no cost to myself and will consist of a series of three shots. 

I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B (unless I already have sufficient immunity), a serious disease.  If in the future I continue to have occupational exposure to blood or other potentially infectious materials (while employed by San Juan College) and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.  

_________ I hereby agree to the terms above and at this time ACCEPT the HBV vaccination series. 

_________ I hereby agree to the terms above and at this time DECLINE the HBV vaccination series or I believe I have sufficient immunity to HBV.

     
Print Name   Social Security
     
     
     
Signature   Date
     
     
     
Job Title   Department
     

The college is under the obligation to make available the Hepatitis B vaccination to all employees who have potential occupational exposure, consistent with OSHA guidelines within 10 working days of their initial assignment.  In the event of an employee who had an exposure incident while working for the college, a post-exposure follow-up will be provided.  Please contact Jim Nelson at x3775 for follow up or other assistance. 

Medical Records

(Maintain this record for the duration of employment plus 30 years.)

 

CONFIDENTIAL

 

 

Gary Lee
San Juan College

Director, Environmental Health Office
4601 College Blvd.
Farmington, NM  87401
(505) 566-3063