* Required Information
Hepatitis B Immunization Acceptance or Declination

I, , understand that due to my occupational exposure to bloodborne pathogens and other potentially infectious materials, I might be at risk of acquiring Hepatitis-B virus (HPV) infection. I have been given the opportunity to be immunized with the Hepatitis-B vaccine, free of charge.

Immunization with Hepatitis-B vaccine

I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis-B and, if contracted, there is a risk of chronic disease, liver cirrhosis, liver cancer or death. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be immunized to Hepatitis-B, I can receive a vaccination series at no charge.