APPENDIX B
(continued)
UNIVERSITY OF WISCONSIN - LA CROSSE
Authorization Form for Hepatitis B Immunization
This form is required to fulfill the requirements of 29 CFR 19190.1030. Personally identifiable information will not be used
for secondary purposes. Note: Return this completed document to Human Resources (Graff Main Hall, Room 144).
**************************************************************************************************
ACCEPT
I have read the information on this form and have had any questions I have related to the vaccine answered by my healthcare
provider. All questions I asked were answered to my satisfaction. I understand the benefits and risks of hepatitis type B
immunization and request that the vaccine be given to me. To the best of my knowledge I am not pregnant at this time, and
there is no other reason that I should not receive the vaccine.
I understand that if I have additional medical questions or concerns I may consult either a private physician of my choosing
or a UW - La Crosse Health Center Physician prior to making a decision about receiving the vaccine. You may request a
copy of this document for your records.
Social Security Number: _____________________________
Name:
(please print)
Address:
Signature: _________________________________________
City, State, Zip:
Date: ____________________________________________
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DECLINE
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 vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring hepatitis B, a serious liver 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. You may request a copy of this document for your records.
Name:
Social Security Number: _____________________________
(please print)
Address:
Signature: _________________________________________
City, State, Zip:
Date: ____________________________________________
**************************************************************************************************
DECLINE - ALREADY VACCINATED
I have read the information on this form and have had an opportunity to ask questions of my healthcare provider. All
questions I asked were answered to my satisfaction. I have previously received the hepatitis B vaccination series. Therefore,
I do not require vaccination at this time. However, I wish to be offered a booster shot if recommended in the future. You
may request a copy of this document for your records.
Name:
Social Security Number: _____________________________
(please print)
Address:
Signature: _________________________________________
City, State, Zip:
Date: _____________________________________________
APPENDIX B
(continued)
UNIVERSITY OF WISCONSIN - LA CROSSE
Hepatitis B Vaccination History Form
Note: An employee with occupational exposure to bloodborne pathogens, who has decided to request the
Hepatitis B vaccination, shall complete this form and bring it to the Health Center during their first
vaccination appointment. The employee may have to contact their healthcare provider(s) to gather some
of this information.
Employee Name:
Date of Birth:
Person ID Number:
(Appears on earnings statement)
1. Have you been vaccinated against Hepatitis B? (circle)
Note: If you circled NO, skip remaining questions and sign at the bottom.
YES
NO
2. What type (if known) hepatitis B vaccine was used?
3. What is your vaccination status? (circle number of doses)
1
2
3
booster
4. Provide the date of each vaccination. (Month\Day\Year)
first dose:
\
\__________
second dose:
\
\__________
third dose:
\
\__________
booster dose:
\
\__________
5. Was the deltoid muscle (upper arm) the injection site? (circle)
YES
NO
If NO, what was the injection site?
This form is required to fulfill the requirements of 29 CFR 1910.1030. Personally identifiable information will
not be used for secondary purposes. This information is true to the best of my knowledge.
Employee Signature:
Date:
__________
APPENDIX B
(continued)
UNIVERSITY OF WISCONSIN - LA CROSSE
Hepatitis B Vaccination Chargeback Form
FROM:
Brian Allen, MD
Student Health Center, Director
TO:
Business Services
Graff Main 125
The Health Center is authorized to chargeback for Hepatitis B Vaccination expenses for a UW-L employee
receiving this vaccination pursuant with OSHA regulation 29 CFR 1910.1030. The supervisor or manager
signature authorizes this transfer.
Supervisor\Managers Signature:
Date: ___________________________
Person ID Number for employee receiving vaccination: ________________________________________
Debit (Custodial Services) Account Number: ________________________________________________
Debit Amount: $180.00
Credit (Health Center) Account Number: ____________________________________________________
Credit Amount: $ - 180.00