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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Circular No. 92-4 - Appendix A

HEPATITIS B VACCINE DECLINATION

    I understand that because of 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.

    I have read, discussed and understand the potential risks associated with declining the vaccine.

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Employee's Name (Typed or Printed)

_____________________________________
Employee's Signature

_________________
Date

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Witness's Signature

_________________
Date


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