Hepa B Vaccine Consent Form

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OLIVAREZ COLLEGE TAGAYTAY

E.Aguinaldo Hi-Way, Brgy.San Jose, Tagaytay City

Hepatitis B Vaccine
Consent/Refusal Form

____Consent

I understand that I must receive 2 doses of the vaccine during a 6-month period,
at the scheduled dates, in order to achieve maximum protection. However, as with all
vaccines, there is no guarantee that I will become immune to Hepatitis B or that I will not
experience side effects. I understand that I should NOT receive this vaccine
if:
1.I am allergic to yeast (e.g. bread) or any other component of the vaccine. I
should tell my doctor if I have any severe allergies;
2.I have had an allergic reaction to a previous dose of Hepatitis B vaccine;
3.I am moderately or severely ill at the time the vaccine is scheduled
(e.g., I have a fever or I am immunocompromised).
4.I am pregnant, planning a pregnancy, or breastfeeding during the course of the
Hepatitis B vaccine. If I become pregnant while receiving the vaccination series, I
will notify both my obstetrician and my occupational care provider and
discontinue vaccination.
I understand that the Hepatitis B vaccine is being offered due to the potential
risk of occupational exposure to HBV, and that the injections are being administered for
a job-related reason and not for the purpose of providing general health care. This
vaccine is only part of the protection needed for safe job performance.
I understand that if I stop studying before completing the series, the
School is not obligated to provide future vaccines. I understand that it is my
responsibility, and I agree to make arrangements to complete the series with
inoculations at 1 and 6 months after the initial dose.

_____________________________ _____________________________
Signature over Printed Name of Student Signature over Printed Name of Guardian
____Refusal

I understand that, due to my risk for 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 the Hepatitis B
vaccine at no charge to myself. However, I decline the 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 want to be vaccinated with the Hepatitis
B vaccine, I can receive the vaccination series at no charge to me. I have read the
Hepatitis B Vaccine Information Statement and have had the opportunity to ask
questions and understand the benefits and risks of the Hepatitis B vaccination. I do not
wish to receive the Hepatitis B vaccine and decline vaccination.

_____________________________ _____________________________
Signature over Printed Name of Student Signature over Printed Name of Guardian

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