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Resident/Fellow Checklist
2022-2023
HEPATITIS-B VACCINE DECLINATION FORM
Last Name
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First Name
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Middle Initial
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Last Four Numbers of U.S. Social Security Number
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Department/Section
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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.
Please Check One
Vaccine Choice (Please refer to Resident/Fellow Immunization Data form for dates)
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I do not want the Hepatitis B vaccination at this time.
I have received prior Hepatitis B immunization.
Signature of Resident Physician
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Signature Date
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