Hepatitis B Form Hepatitis B Form "*" indicates required fields Please complete one of the two sections below. Patient Name:* First Hepatitis B Vaccination I have received and read the safety manual, On Call Staffing Solutions Safety and Orientation Manual, and specifically read the section involving blood borne pathogens, as well as the information about Hepatitis B Vaccinations. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no Signature: Printed Name:* Date MM slash DD slash YYYY Hepatitis B Vaccination I have received and read the safety manual, On Call Staffing Solutions Safety and Orientation Manual, and specifically read the section involving blood borne pathogens, as well as the information about hepatitis B vaccinations. I understand I have been given the opportunity to receive the vaccinations at the company’s expense. Below is my vaccination information: The dates of the Hepatitis B series are:month/year Add Remove"For all vaccinations received while preparin9 or working on a travel assignment. I have attached a receipt and request the company to:Signature: Printed Name:* Date MM slash DD slash YYYY
