Health Services, Waiver Form For Hepatitis B Immunization
Volunteer State Community College | Student Services Division

General Information | New Employee | Manuals | Faculty/Staff

Health Services hours are: 8:00 a.m. - 4:30 p.m.
Early and Late appointments can be scheduled through Health Services

View the Bloodborne Pathogen Video

Click here to view the PDF version

ALL employees should complete the forms listed below ONLY one time.  If you have never completed these forms, please print the forms and return the completed forms to Health Services.

NAME_______________________________ SIGNATURE_____________________________

SS #___________________________DEPARTMENT_________________________________

FACILITY________________________________________DATE_______________________

I WAIVE THE HEPATITIS B VACCINE:

I understand that HIV and HBV are viruses that are transmitted primarily through sexual contact, but they can be found in any body fluid, especially blood and blood products.

______            I work in one of the identified high-risk areas:  (Security, Health Services, Maintenance, or I am an instructor in Allied Health, Physical Education or I am the

Coach, manager, or trainer.   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.

______            I do not work in one of the identified high risk areas and am declining the

Hepatitis B immunization.

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I HAVE RECEIVED THE IMMUNIZATION FOR HEPATITIS B.  (Attach copy of previous record)

Date received _________________________Type of vaccine____________________________

Agency/Institution administering vaccine_____________________________________________

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TITER TEST     (attach copy of lab report)

Titer Results___________________________  Date___________________________________