APPENDIX XIII: HEPATITIS B VACCINATION DECLINATION

UNIVERSITY OF TENNESSEE - KNOXVILLE

HEPATITIS B VACCINATION DECLINATION (MANDATORY)

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 hepatitis B vaccine, at no charge to myself. However, I decline depatitis B vaccination at this time. I understand that by declining this vaccination, I continue to be at risk of acquiring hepatitis B, a serious disease. 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 charge to me.

Original: Department Files

Copy: Department of Environmental Health and Safety

          Employee