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2. First and Last Name*
3. Department*
4. Email*
5. Position*
7. 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.*

   1. Yes
9. 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. *

   1. Yes
11. 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. *

    1. Yes
13. 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.*

    1. Yes
15. Please check ONE option*

    1. I have elected to accept the Hepatitis B vaccination shots.
    2. I have already completed the Hepatitis B vaccination shots.
    3. I have elected to have a Titer Test to confirm immunity.
    4. I have elected not to accept the Hepatitis B vaccination shots.
19. 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
21. Want to learn more about Hepatitis, the following link will take you to more information.
    CDC-Hepatitis B Information
23. “ 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.”*

    1. Yes
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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