HomeMy WebLinkAbouthepatitisbvaccinationdeclinationformBody Art Program
Alameda County Department of Environmental Health
Solid/Medical Waste Management
1131 Harbor Bay Parkway, Alameda, CA. 94502 Phone: (510)567-6790 Fax: (510) 337-9234
https://deh.acgov.org/index.page
HEPATITIS B VACCINATION DECLINATION FORM
FOR OFFICIAL USE ONLY
FACILITY NAME: FACILITY ADDRESS: CITY: STATE: ZIP CODE: FACILITY EMAIL ADDRESS: FACILITY PHONE NUMBER:
DECLINATION STATEMENT*
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 me; 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.
SIGNATURE: DATE: (mm/dd/yyyy) PRINT NAME / TITLE:
FA# PR#
ENVIRONMENTAL HEALTH SPECIALIST:
APPROVED NOT APPROVED DATE:
FACILITY INFORMATION