Winona State University

College of Nursing and Health Sciences

Department of Nursing

    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 I will notify and submit documentation to the nursing office that the series has been completed.

Signature:_______________________     Date:________________