Hepatitis B Vaccination Decision Form

2. First and Last Name*

3. Department

4. Position

6. I understand that, as a result of performing my job duties, I may face contact with blood and potentially infectious materials. This contact may put me at risk of acquiring Hepatitis B virus (HBV) infection.*

   1. Yes

8. I understand my employer has offered me the opportunity to be vaccinated with Hepatitis B vaccine at no cost to me and I also understand the importance of taking active steps to reduce the risk of infection. If I need a booster shot, it will be offered at no cost. *

   1. Yes

10. I understand that if I decline this vaccine, I could be at risk of contracting Hepatitis B. I understand that at any time, I can change my mind and accept the Hepatitis B vaccination, if vaccine is available.*

    1. Yes

12. Please check ONE option*

    1. I have elected to accept the Hepatitis B vaccination shots.
    2. I have already completed the Hepatitis B vaccination shots.
    3. I have elected to have a Titer Test to confirm immunity.
    4. I have elected not to accept the Hepatitis B vaccination shots.

14. If you previously completed the Hepatitis B vaccination series please indicate the date and location of where the series was completed.

18. Public Safety Employees (Fire, Police and Sheriff) who decline this vaccine without proper medical documentation to support a health risk to the employee will forfeit their rights under Section 65.2-402.1 of the Virginia Workers’ Compensation Act, “Infectious Disease Presumption.”

20. I understand that I will forfeit my rights to the “Infections Disease Presumption” under Section 65.2-402.1 of the Virginia Workers’ Compensation Act if I decline this vaccination.

    For Public Safety Only

    1. Yes
22. Want to learn more about Hepatitis, the following link will take you to more information.
    CDC-Hepatitis B Information

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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