FORM 3
ELKHORN PUBLIC SCHOOLS
HEPATITIS B VACCINE DECLINE
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 Name: ________________ (Please Print)
Employee Signature: ________________
Employee Job Title: ________________
Employee Social Security Number: ________________
Date: ________________