VA Greater Los Angeles Healthcare System
Administrative Medicine (Employee Health)
HEPATITIS B VACCINE CONSENT / DECLINATION FORM
HEPATITIS B: Hepatitis B is a viral infection caused by the Hepatitis B virus (HBV), which causes
death in 1-2 % of patients, including more than 300 healthcare workers annually. Most people with
Hepatitis B recover completely but about 5-10 % of infected individuals become chronic carriers of the
virus. Most of these people have no symptoms, but can continue to transmit the disease to others.
Some may develop chronic active hepatitis and cirrhosis of the liver, the virus also appears to be causative
factor in the development of liver cancer. Immunization against hepatitis B can prevent acute hepatitis and
reduce sickness and death from chronic active hepatitis, cirrhosis and liver cancer.
THE VACCINE: Hepatitis B vaccine (HBV vaccine) is made using recombinant DNA
(Deoxyribonucleic Acid) technology. The vaccine contains nothing of human origin! A high
percentage of healthy people who receive three doses of this vaccine achieve high levels of surface
antibody (HBsAb) and protection against Hepatitis B. Full immunization requires three doses of
vaccine given over a six month period. There is no evidence that the vaccine has ever caused
Hepatitis B or AIDS (Acquired Immune Deficiency Syndrome). Individuals infected with HBV
prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization.
The duration of immunity is unknown at this time but long term protection is probable.
POSSIBLE VACCINE SIDE EFFECTS: The incidence of side effects is very low. No serious
side effects have been reported with the vaccine. A few individuals have reported tenderness and
redness at the injection site. Low grade fever may occur. Rash, nausea, joint pain, and mild fatigue
have also been reported. The possibility exists that more serious side effects may be identified in
the future. The vaccine should not be taken by persons allergic to yeast or other components of the
vaccine, or by pregnant or nursing women, without consulting their personal healthcare provider.
IF YOU HAVE ANY QUESTION ABOUT HEPATITIS B OR THE HEPATITIS B VACCINE,
PLEASE ASK PRIOR TO BEGINNING THE SERIES OF SHOTS.
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I have read the above statement about hepatitis B and the hepatitis B vaccine.
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I have had an opportunity to ask question and understand the benefits and risks of hepatitis B
vaccination. I understand that I must have three (3) doses of vaccine to develop immunity. There
is no guarantee that I will become immune or that I will not experience any adverse effects from
the vaccine.

I understand that I may decline the vaccine. At any time in the future while I am still employed
in any VA Greater Los Angeles Healthcare System (VAGLAHS) facility, I may request to begin the
vaccine series.
( ) I request that I be given the hepatitis B vaccination series (
) __________
( ) I have completed the HBV vaccination series or have been diagnosed with hepatic B in the past ( ) _______
( ) I do not wish to take the HBV vaccination series at this time ( ) ___________
( ) I will return at a later date to be given the Hepatitis B vaccination series (
_________________________________
Printed Name
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SS #
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Signature
) __________
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Date