PeopleCare Health Services
Hepatitis B Consent or Declination
Employee Acknowledgement Form
Hepatitis B is the most common serious liver infection in the world. It is caused by the hepatitis B virus that attacks
the liver. The virus is transmitted through blood and infected bodily fluids. This can occur through direct blood-to-blood
contact, unprotected sex, use of un-sterile needles, and from an infected woman to her newborn during the delivery
process. The good news is that there is a simple blood test to find out if you have been infected. There is also a safe and
effective vaccine to protect you and your loved ones against hepatitis B.
Most healthy adults (90%) who are infected will recover and develop protective antibodies against future hepatitis B
infections. A small number (5-10%) will be unable to get rid of the virus and will develop chronic infections.
Transmission of Hepatitis B
Hepatitis B is transmitted through blood and infected bodily fluids. This can occur through:
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Direct blood-to-blood contact
Unprotected sex
Using non-sterile needles
From an infected woman to her newborn baby during the delivery process
Other possible routes of infection include sharing sharp instruments such as razors, toothbrushes or earrings. Body
piercing, tattooing and acupuncture are also possible routes of infection unless sterile needles are used
Hepatitis B is NOT transmitted casually. It cannot be spread through sneezing, coughing, hugging or eating food
prepared by someone who is infected with hepatitis B. Everyone is at some risk for a hepatitis B infection, but some
groups are at higher risk because of their occupation or life choices.
Vaccination
The vaccine is readily available at your doctor's office or local health clinic. Three doses are generally required to
complete the hepatitis B vaccine series.
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First Injection - At any given time
Second Injection - At least one month after the first dose
Third Injection - Six months after the first
If you have had your Hepatitis B vaccination in the past and have a copy, please provide it to the office for your
file.
(Over)
PeopleCare Health Services
www.PeopleCareHS.com
I have read the memorandum about the Hepatitis B vaccine (Recombivax) and understand the risk of Hepatitis B inherent
to me in the workplace. I have had the opportunity to ask questions about Hepatitis B and the vaccine and understand
that I must have three doses of vaccine to confer immunity. However, as with all medical treatment, there is no guarantee
that I will become immune or that I will not experience an adverse side-effect from the vaccine. I agree to hold PCHS
harmless for any adverse reactions to the vaccine.
Choose either to decline the vaccination or to give consent that you will pay for and ensure receipt of vaccination.
DECLINATION (If you do not already have proof of Hepatitis B Vaccines, you must also fill out this section, even if you
have requested the vaccine be given to you.)
By my signature below, I acknowledge the receipt of the Hepatitis B information and decline the Hepatitis B vaccine.
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Employee’s Name (Print)
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Employee’s Signature
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Agency Representative Signature
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Date
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Date
CONSENT FOR VACCINATIONS
I understand that it is my responsibility to pay for and ensure the completion of the series and notify PCHS and
provide proof of vaccination upon completion.
I attest to the fact that the following are true:
PREGNANT:
Yes____ No____
ALLERGIC TO YEAST:
Yes____ No____
ALLERGIC TO THIOMERSAL:
Yes____ No____
CURRENTLY ILL:
Yes____ No____
I acknowledge, by my signature, that I am responsible for returning for the completed series of vaccinations. In the event I
terminate my employment with PCHS prior to the completion of the vaccination and follow-up blood test, PCHS is under
no obligation to complete the vaccination or blood tests.
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Employee’s Name (Print)
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Employee’s Signature
___________________________________
Agency Representative Signature
__________________
Date
PeopleCare Health Services
www.PeopleCareHS.com
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Date