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Hepatitis B Vaccination Decision Form

  1. 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.*
  2. 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. *
  3. 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.*
  4. Please check ONE option*
  5. 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.”
  6. 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
  7. Leave This Blank:

  8. This field is not part of the form submission.