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Appendix A

BETH-EL COLLEGE OF NURSING AND HEALTH SCIENCES
OF THE UNIVERSITY OF COLORADO AT COLORADO SPRINGS

Hepatitis B Vaccine Declination  

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.  Many hospitals and clinical agencies where I will have student experiences require this immunization.  However, I decline hepatitis B vaccine at this time.  I understand that by refusing to receive this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.  Since I will continue to have occupational exposure to blood or other potentially infectious materials, I may have the vaccine later and will inform the College of my status.

______________________________________                     ________________

Name                                                                                 Date

_______________________________________                     ________________

Witness                                                                              Date

Employee Health/Infection Control

May 1992