UNIVERSITY OF SOUTH CAROLINA
CLINICAL IMMUNIZATION REQUIREMENTS INFORMATION FORM
______
Name: ___________________________________________ (H) _________________ (W) ___________________
Last
First
MI
Phone
Phone
Address:__________________________________________________________ Dept. ______________________
Number and Street
City
State
Zip
Last 4 digits SSN #:____________________ Department Code: ____________________ Fund: _______________
Job Description: ______________________________________ Responsibilities: _________________________
Requested by: ___________________________________________________________ Date: _______________
Supervisor
Signed:_________________________________________________________________ Date:________________
**Must be approved by Environmental Health & Safety Designee (Occupational Health)**
I. IMMUNIZATION INFORMATION:
The above listed individual has been requested to receive the following immunizations:
1. ( ) Chest X-Ray PA Single view only
2. ( ) Blood Lead Level
3. ( ) HBV: Vaccine or Titer (Anti HBs) If HBV is offered, employee must complete Item II, OSHA
Bloodborne Pathogen Requirements Section, below.
Other/Comments:
______________________________________________________________________________________
II. OSHA BLOODBORNE PATHOGENS REQUIREMENTS SECTION:
The University of South Carolina offers the Hepatitis B vaccination to individuals with occupational exposure to blood or
other potentially infectious material. This vaccination is given at no charge to the employee. While vaccination is
encouraged, it is not mandatory. You must read the CDC Information on Hepatitis B Vaccine, located on page two (2)
prior to submission of this form.
Print Name: __________________________________ Signature: ____________________________
Please check one of the following:
I have previously been vaccinated for Hepatitis B. (Approx. Date: __________________)
I have not been vaccinated but would like to receive the vaccination.
I have not been vaccinated and do not wish to be vaccinated at this time. If you decline, please read and sign
declination below.
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 infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no
charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this
vaccination, I continue to be at risk of acquiring Hepatitis B. I understand that I may change my mind at any time and elect
to receive the vaccination free of charge.
__________________________________
Signature
____________________
Date
The completed form should be sent to:
USC Environmental Health and Safety, 306 Benson School, Columbia, SC 29208
Attention: Occupational Health Physician
EHS-F-146
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Issue Date: 5/2/14
Approved: TS
*** You MUST make an appointment with the Thomson Student Health Center Immunization
Clinic to receive your required immunizations. The immunization clinic can be reached at 803-7779511. Please bring your immunization records with you for your scheduled appointment.
***You must read the CDC Information on the Hepatitis B Vaccine, located prior to contacting the
Student Health Center.
CDC Information on Hepatitis B Vaccine
The Hepatitis B Vaccination Process:
 The Hepatitis B process involved three shots. The second shot is given one month after the first
shot, and the third shot is given five months after the second shot.
 It is very important to receive all three of the vaccines. This series gradually builds up the body’s
immunity to the hepatitis B virus. Complete immunity is not reached until all three vaccines are
received.
Who should NOT get hepatitis B vaccine?
 Anyone with a life-threatening allergy to yeast, or to any other component of the vaccine, should
not get hepatitis B vaccine. Tell your provider if you have any severe allergies.
 Anyone who has had a life-threatening allergic reaction to a previous dose of hepatitis B vaccine
should not get another dose.
 Anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait
until they recover before getting the vaccine.
 Pregnant women who need protection from HBV infection may be vaccinated.
Hepatitis B vaccine risks
Hepatitis B is a very safe vaccine. Most people do not have any problems with it. The vaccine contains
non-infectious material, and cannot cause hepatitis B infection.
The following mild problems have been reported: Soreness where the shot was given (up to about 1 person
in 4). • Temperature of 99.9°F or higher (up to about 1 person in 15).
Severe problems are extremely rare. Severe allergic reactions are believed to occur about once in 1.1
million doses. A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine
causing serious harm, or death, is extremely small. More than 100 million people have gotten hepatitis B
vaccine in the United States.
What if there is a moderate or severe reaction?
Look for any unusual condition, such as a severe allergic reaction, a very high fever or behavior changes.
Signs of a serious allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a
fast heartbeat, dizziness, and weakness.
What should I do?
If you think it is a severe reaction or other emergency, call 9-1-1, or get the person to a doctor right away.
Tell your doctor what happened, the date and time it happened, and when the vaccination was given. • Ask
your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting
System (VAERS) form. Or you can file this report through the VAERS web site at www.vaers.hhs.gov, or
by calling1-800-822-7967.VAERS does not provide medical advice.
EHS-F-146
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Issue Date: 5/2/14
Approved: TS