FORM 5 HEPATITIS B VACCINE PHYSICIAN APPROVAL

FORM 5

ELKHORN PUBLIC SCHOOLS

HEPATITIS B VACCINE PHYSICIAN APPROVAL

I understand that due to the below mentioned employee’s potential occupational exposure to blood or other potentially infectious materials he/she may be at risk of acquiring Hepatitis B virus (HBV) infection. I authorize Elkhorn Public Schools to immunize this employee against the Hepatitis B Virus (HBV).

Employee Name: ________________ (Please Print)

Employee Signature: ________________

Employee Job Title: ________________

Employee Social Security Number: ________________

Date: ________________

Physician Name: ________________ (Please Print)

Physician Signature: ________________

Date: ________________