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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 if I decline this vaccine I will be at risk of contracting Hepatitis B.*

  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.