Skip to Main Content
Residents
Business
Government
Services
Discover
How Do I...
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
City Clerk
City Council
City Manager
Citywide
Codes Compliance
Commissioner of the Revenue
Development
Emergency Management
Engineering
Fire Department
Human Resources
Human Services
Information Technology
Juvenile Services
Parks & Recreation
Planning
Police Department
Police Ride-Along
Public Works
Purchasing
Risk Management
Treasurer
Voter Registrar
Waterworks
By
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.
Sign in to Save Progress
Hepatitis B Vaccination Decision Form
This form has been modified since it was saved. Please review all fields before submitting.
First and Last Name
*
Department
Position
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.
*
Yes
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.
*
Yes
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.
*
Yes
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.
If you previously completed the Hepatitis B vaccination series please indicate the date and location of where the series was completed.
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.”
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
Yes
Want to learn more about Hepatitis, the following link will take you to more information.
CDC-Hepatitis B Information
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
* 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
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow