Consent Form for Hepatitis B Vaccine

Consent Form for Hepatitis B Vaccine – Blood borne Pathogens Exposure Control

Despite the use of universal precautions, I understand that my normal work responsibilities may bring me in contact with Hepatitis B through blood, tissue and/or body fluid exposure. As further protection from the Hepatitis B virus, the Agency has offered me the Hepatitis B vaccination series free of charge.

I have read the information sheet that lists the indications, benefits, and presently known side effects of Hepatitis B vaccine, have had an opportunity to ask questions, and have had them answered to my satisfaction.

I understand that I must receive three (3) doses of vaccine over a period of six (6) months to confer optimal immunity. I understand, however, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse reaction to the vaccine. In the event that I experience any adverse side effects or do not become immune from the vaccine I hereby hold the Agency harmless from any and all liability to the extent permitted under the law. In the event that I should terminate employment at the Agency prior to receiving all three (3) doses of hepatitis B vaccine, understand that it will be my responsibility to complete the vaccination series on my own initiative and at my own expense.