ENVIRONMENTAL HEALTH AND SAFETY
700 UNIVERSITY BLVD., MSC 221
KINGSVILLE, TEXAS 78363
361-593-4131  FAX 361-593-4755
REQUEST TO RECEIVE HEPATITIS B VACCINE
(To Be Kept in Employee’s Medical File)
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
acknowledge that I have been provided information on the hepatitis B vaccine, including
information on its effectiveness, safety, method of administration and the benefits of
being vaccinated. I have been given the opportunity to be vaccinated with hepatitis B
vaccine, at no charge to myself, and request to receive the vaccination series.
Employee Signature
Date
Vaccination series given:
(Dates)
(Administered by)
HEPATITIS B VACCINE DECLINATION
(To Be Kept in Employee’s Medical File)
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 hepatitis B vaccine at this time. I understand that, by
declining this vaccine, 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.
Employee Signature
Date