Hepatitis B Vaccine Acceptance/Declination Form

Rev. 5/27/15
Hepatitis B Vaccine Acceptance/Declination Form
Please Click Here to Submit by
You must complete this form to receive credit for your Blood Pathogen training.
CHECK ONE OF THE OPTIONS BELOW, THEN ACKNLOWLEDGE & COMPLETE THE INFORMATION BELOW:
Please know that you can change your decision at any time and discuss questions by contacting the EHS
Occupational Health Nurse at 858-534-8225 or [email protected].
Check option #1 to request vaccination at this time.
#1. I certify that I have been offered and will participate in the Hepatitis B Vaccine Program free of
charge, which includes serological testing at 1-2 months post-vaccination. I understand that I must request
an appointment for these free medical services within ten (10) working days, by contacting UCSD Center for
Occupational and Environmental Medicine (COEM), Campus 858-657-1600, Hillcrest 619-471-9210.
OR
Read option #2 and select a declination reason if you do not want or need to receive Hepatitis B
vaccination at this time.
#2. I understand that due to my occupational exposure to blood or OPIM 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. 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 OPIM and I want to be vaccinated with hepatitis B
vaccine, I can receive the vaccination series at no charge to me.
Declination Reason:
I decline because I have received the 3-dose Hepatitis B vaccination in the past.
Please send a copy of the vaccination record
(list all 3 dates)
and post-vaccine titer*.
I decline because I have evidence of immunity (send a copy of the antibody titer
record*).
I decline because I will not be working with human blood, tissues, cells, or cell lines.
Other reason for declination;
please explain:
*Send prior vaccination records and/or immunity records to the EH&S Occupational Health
Nurse, fax 858-534-7561 or mail code 0090. Call 858-534-8225 if you have questions.
(your full name)
By checking this box, I ,
acknowledge that I have read and I
understand that occupational exposure to blood or other potentially infectious material (OPIM) may present the risk of
acquiring hepatitis B virus (HBV) infection. I understand that I may obtain the Hepatitis B vaccination series and PostExposure Evaluation from the Center for Occupational & Environmental Medicine (COEM) at no cost. Hepatitis B
vaccination is recommended unless: 1) Documentation of prior vaccination and post-vaccination titer is provided to
EHS 2) Medical evaluation identifies that vaccination is contraindicated.
(phone)
(UC employee #)
(department)
Please Click Here to Submit by Email
(your email address)
(your principal investigator/supervisor)
(date)