ELKHORN PUBLIC SCHOOLS
HEPATITIS B VACCINE INFORMED CONSENT
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. I hereby authorize my employer to vaccinate me against Hepatitis B virus (HBV). I understand that the injections are given over a period of months before they are effective in preventing this disease.
Employee Name: ____________________(Please Print)
Employee Signature: ____________________
Employee Job Title: ____________________
Employee Social Security Number: ____________________