Skip to Main Content
Do Not Show Again
How Do I...
Select a Category
Commissioner of the Revenue
Parks & Recreation
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Hepatitis B Vaccination Decision Form
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
First and Last Name
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.
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.
I understand that if I decline this vaccine, I could be at risk of contracting Hepatitis B, however, should I at any time, change my mind and opt to accept the Hepatitis B vaccination, I may do so and it will be offered at no cost if the vaccine is available. I understand that I will also be required to complete a new ‘Hepatitis B Vaccination Decision Form’ at that time.
I understand that if I am now or ever become a sworn public safety employee (Fire, Police, Sheriff), and I decline the Hepatitis B vaccination series, should I contract Hepatitis B in the course of my employment due to an exposure, I will forfeit my rights to the “Infections Disease Presumption” under Section 65.2-402.1 of the Virginia Workers’ Compensation Act. I also understand that I may run the risk of my Workers’ Compensation claim being denied.
Please check ONE option
I have elected to accept the Hepatitis B vaccination shots.
I have already completed the Hepatitis B vaccination shots.
I have elected to have a Titer Test to confirm immunity.
I have elected not to accept the Hepatitis B vaccination shots.
The following link will take you to the Hepatitis B Titer Test/Vaccination Schedule Authorization For Services Form. (A completed form must be printed and provided to the facility for testing.)
Hepatitis B Titer Test/Vaccination Schedule Authorization for Services Form
Want to learn more about Hepatitis, the following link will take you to more information.
CDC-Hepatitis B Information
“ I understand to receive an emailed copy of a blank Authorization for Services Form or the CDC information, I MUST provide my email address as requested below.”
Leave This Blank:
Receive an email copy of this form.
This field is not part of the form submission.
* indicates a required field
Property Assessment Search
Agendas & Minutes
Apply for a Job
Newport News Now E-newsletter
Bids & RFPs
Open Budget Portal
Frequently Asked Questions
Project Status Report
GeoHub Newport News
Slideshow Left Arrow
Slideshow Right Arrow