College of Nursing and Health Sciences

Department of Health , Exercise and Rehabilitative Sciences

Athletic Training  Education Program

Hepatitis B Vaccine Declination

Name (please print):____________________________________

Social Security Number:_________________________

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B (HBV) infection.

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. I accept all responsibility for the consequences of my decision to decline.

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.

I also understand that I will bear the expense of the series of vaccine injections, and will notify and submit documentation to the nursing office that the series has been completed.

Signature:______________________________Date:______________