Hepatitis B Vaccine

The Town of Burgaw understands that due to the occupational exposure to blood or other potentially infectious materials, you may be at risk of acquiring Hepatitis B Virus (HBV) infection. The Town of Burgaw is ensuring that the Hepatitis B vaccine and vaccination series and post-exposure follow-up including prophylaxis are:

1. Made available at no cost to the employee;

2. Made available at a reasonable time and place;

3. Performed by, or under the supervision of, a licensed physician or other licensed healthcare professional; and

4. Provided according to the recommendations of the US Public Health Service.

If you wish to have the Hepatitis B Vaccine, sign this form and return it to the Personnel Technician for instructions.

Hepatitis B Vaccine Declination - If you do not want the Hepatitis B Vaccine at this time, read and sign the declination below.

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity tobe vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccinationat this time. I understand that by declining this vaccine, 1 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 vaccine series at no charge to me.