Hepatitis B Vaccination

Vaccination against the Hepatitis B virus (HBV) is provided free of charge to University of Utah employees (including non-employee graduate students) who have exposure to human blood, blood products, certain human body fluids, tissues, organs, and primary cell lines. The HBV vaccination is a series of 3 shots given over a period of 6 months (0, 1-2, 4-6 months).

To sign up for the vaccination series, please fill in the following:

Requested by:(Full name)

Telephone:

Principle Investigator

 Email address:

Location:

Check one:
Vaccination
Titer Check
Finish Series

Hepatitis B Vaccination Declination Form

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.

Date __________________________________

Signature ______________________________

Print Name _____________________________