Hepatitis B VaccinationAcceptance or Declination Form

As an employee of Old Dominion University, you may have occupational exposure to potentially infectious materials, you have the right to receive the Hepatitis B vaccinations series, free of charge to you.

Please read and complete this form by marking the appropriate statements.

Name Name * First Last
Email *
UIN: *
Department *
Date Date * / MM / DD YYYY
Please Check One of the Following: *

Please Check One of the Following: ACCEPT the vaccination. I understand the risks of exposure to blood or other potentially infectious materials involved with my job. I have been given the opportunity to be vaccinated with the hepatitis B vaccine at no charge to myself. DECLINE the vaccination. I understand that due to my occupational exposure to blood or other potentially infectious material (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.
Please check one of the following if you are declining: *

Please check one of the following if you are declining: I am declining because I have previously completed the hepatitis B vaccination series. I am declining because I choose not to have the hepatitis B vaccination series. I am also aware that I may change my mind at a later date.
Please enter your initials to indicate that the information provided on this form is complete and accurate. *