Hepatitis B Vaccination Form Hep B Virus Employee Immunization Election Name* First Last Employee ID (UIN)*Email* Phone Number*Workstation*Select OneAgriLife ResearchTTITEEXTEESTFSGalvestonHealth Science CenterCorpus ChristiKingsvilleCentral Texas (Killeen)Texas A&M InternationalTexas A&M UniversityTexarkanaSan AntonioPrairie ViewCommerceSystem OfficesTarleton State UniversityTVMDLAgriLife ExtensionWest Texas A&MHepatitis B Vaccination*You have the right to request or decline the hepatitis B (HBV) vaccination series. You should have already received training on the risks and prevention of occupational exposure to bloodborn pathogens, including HBV, and had an opportunity to ask questions. If you have not completed the training, please do so before filling out this form.Accept the VaccinationAlready ImmunizedDecline to be ImmunizedREQUEST TO RECEIVE HEPATITIS B VACCINEI have been informed of the biological hazards that exist in my workplace, and I understand the risks of exposure to blood or other potentially infectious materials involved with my job. I understand that I may be at risk of acquiring hepatitis B virus (HBV) infection. I acknowledge that I have been provided information on the hepatitis B vaccine, including information on its effectiveness, safety, method of administration and the benefits of being vaccinated. I have been given the opportunity to be vaccinated with hepatitis B vaccine at no charge to myself. I request to receive the vaccination series.STATEMENT OF CURRENT IMMUNIZATIONBy clicking SUBMIT, I attest that I have already been immunized against hepatitis B virus (HBV) infection.HEPATITIS B VACCINE – DECLINATION STATEMENTBy clicking SUBMIT, I acknowledge that 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 vaccine 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. All of my questions regarding the risk of acquiring hepatitis B virus, and the hepatitis B virus vaccination process, have been answered to my satisfaction.