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Dignity HepB Declination Form

This document summarizes a patient declining recommended vaccinations. The patient works in a job with occupational exposure to blood and other infectious materials, putting them at risk for hepatitis B. While the hepatitis B vaccine was recommended and available free of charge due to this risk, the patient declined it at this time. The patient understands this decision continues their risk of acquiring hepatitis B. They can receive the vaccine in the future if they continue high-risk work and want the vaccination. The patient read vaccine information sheets, discussed risks and benefits with their provider, and understands consequences of not being vaccinated, but has still decided to decline the recommended vaccines. [/SUMMARY]

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Clarissa Shenah
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101 views1 page

Dignity HepB Declination Form

This document summarizes a patient declining recommended vaccinations. The patient works in a job with occupational exposure to blood and other infectious materials, putting them at risk for hepatitis B. While the hepatitis B vaccine was recommended and available free of charge due to this risk, the patient declined it at this time. The patient understands this decision continues their risk of acquiring hepatitis B. They can receive the vaccine in the future if they continue high-risk work and want the vaccination. The patient read vaccine information sheets, discussed risks and benefits with their provider, and understands consequences of not being vaccinated, but has still decided to decline the recommended vaccines. [/SUMMARY]

Uploaded by

Clarissa Shenah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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VACCINE DECLINATION

The indicated immunizations have been recommended:

□ Tdap Declined O
□x Measles, Mumps, Rubella (MMR) Declined □x
( p
D Varicella chicken ox ) Declined D
g
D Menin ococcal Declined D
D Rabies Declined D
� Hepatitis B Declined �
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 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 vaccine, 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.
Initial ---

! have read the Center for Disease Control and Prevention's (CDC) Vaccine Information
Sheet(s) explaining the disease(s) they prevent. I have had the opportunity to discuss
these with my healthcare provider, who has answered all of my questions regarding the
recommended vaccine(s). I understand the following:

• The purpose of and the need for the recommended vaccine(s).


• The risks and benefits of the recommended vaccine(s).
• The consequences may include:
-Contracting the illness the vaccine should prevent
-Transmitting the disease to others
• My healthcare provider and the CDC have all strongly recommended the vaccine(s)
be given.

Nevertheless I have decided to decline the vaccine(s) recommended to me, as indicated


above, by checking the appropriate box.

I know that failure to follow the recommendations about the vaccine may endanger my
health and others that I may be in contact with.·

I know that I may re-address this issue with my healthcare provider at any time, and I
may change my mind and accept the vaccination anytime in the future.

Comment: _________________________
I acknowledge that I have read the document in its entirety and fully understand it.

PrintName_______________ Employee#_____

Signature________________
. Date_______

Witness_________________ Date_______
8/14/17

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