Policies = Series 400 – Personnel = 404 Employee Health and Well-Being = Policy 404.04 Bloodborne Pathogens = Administrative Rules and Procedures to Implement Policy 404.04 = FORM 4 HEPATITIS B VACCINE INFORMED CONSENT

FORM 4 HEPATITIS B VACCINE INFORMED CONSENT

FORM 4

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: ____________________

Date: ____________________