736 Irving Ave.
Syracuse, NY 13210
Phone: (315) 470-7269
Fax: (315) 470-1370
crouse.org/nursing
Hepatitis B Information/Declination Form
RISKS
Individuals who work in health care settings are at risk for contracting blood borne diseases. The
Occupational Safety and Health Administration (OSHA) issued a set of regulations designed to protect
both patients and health-care workers. Specific training will be provided to students as soon as they begin
the nursing program in order to minimize the risk.
HEPATITIS B
Hepatitis B is a blood borne viral infection. Most people with Hepatitis B recover completely, but the
infection can be fatal and approximately 5-10% of those infected can become chronic carriers of the virus.
Most chronic carriers have no symptoms but can continue to transmit the disease to others. Chronic
carriers may develop chronic active Hepatitis, cirrhosis and possible liver cancer.
VACCINATION
A vaccine for Hepatitis B has been developed, tested extensively and found to be effective in producing an
antibody, and thus protection against Hepatitis B, in 95-96% of health persons. Some persons who have
received the vaccine have complained of redness and soreness at the injection site. Other reported side
effects have been low grade fever, rash, nausea, joint pain and mild fatigue. Long-term side effects are
unknown.
The vaccine is administered in three doses with one month between dose one and two, and six months
between dose one and three. The series must be completed in order to be effective. The duration of the
immunity is presently unknown, but thought to be in the range of 5-8 years.
OSHA strongly encourages students to be vaccinated: “Risks among health-care professionals vary during
the training and working career of each individual but are often highest during the professional training
period. For this reason, when possible, vaccination should be completed during training in school of
medicine, dentistry, nursing, laboratory technology, and other allied health professions before workers
have their first contact with blood.” (OSHA: “Final Rule” Fed Reg. Pp 64089).
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DECLINATION
I have read the above statements about Hepatitis B and the Hepatitis B vaccine.
I have decided NOT to accept the Hepatitis B vaccine OR I have not completed the series.
Name:
Please Print
Signed:
Student Signature
Date
Witness
Date
Signed:
Lack of compliance may impact course registration.
S:\My Files\CHNetShare\Departmental Forms\College of Nursing\Student Health Forms\Hepatitis B Decline.doc 1/18/12, 3/7/13