Residency/Fellowship Programs – Decline Hepatitis B Vaccine

Resident/Fellow Checklist
2022-2023
HEPATITIS-B VACCINE DECLINATION FORM

Name(Required)

First Middle Initial Last

Last 4 of Social Security Number

Format : NNNN

Department/Secton

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk for 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 vaccination, 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.

Choose 1 below to Decline:

Hepatitis Vaccine Choices

I do not want the Hepatitis B vaccination at this time.

I have received prior Hepatitis B immunization.

Signature of Resident Physician(Required)

Date Signed(Required)

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