Hepatitis B Form

NAME:                                                                                  

SSN:                                     

DOB:                                     

ADDRESS:

 

STREET:                                                                              

STATE:                                    ZIP                                       

CITY:                                                                                    

PHONE:                                                              

___ I have received the Hepatitis B Vaccine and have as stated on the record of my Physical Exam and affirmed by my physician or employee health service.

___ I am currently immune as stated on the record of my Physical Exam and affirmed by my physician or employee health service.

___ I refuse to receive the Hepatitis B Vaccine for the following Reason:                                                                                                                                                         .

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the Hepatitis B virus (HBV) infection.  I understand that by declining the vaccine, I continue to be at risk of acquiring Hepatitis B and release Lab Force, Inc., (DBA NURSEPARTNERS™) from any liability associated with this risk.

___ I have not received the Hepatitis B vaccine because:                                                                                                                                                                         .

I will be vaccinated on:                                                 .                                                Approximate date you plan to be inoculated.

 

 

 

 

Employee’s Signature                                                                                               Date