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Hepatitis B Vaccination Decision Form
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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 if I decline this vaccine I will be at risk of contracting Hepatitis B.
Please check ONE option
I have elected to accept the Hepatitis B vaccination shots.
I have 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
Want to learn more about Hepatitis, the following link will take you to more information.
CDC-Hepatitis B Information
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