University Hospital of Brooklyn OWNSTATE Collage of Medicine Medical Center School of Graduate Studies College of Nursing College of Health Related Professions StudentiEmployee Health Service HEPATITIS B CONSENT have read and understand the (Print Nama) ‘Statement about Hepatitis 8 vaccine. {have had an opportunity to ask questions and understand the benefits and risks of Hepatitis B vaccination. | understand that | must have three (3) doses of vaccine to confer immunity. However, as with all medical treatment, there is no guarantee that | will become immune or that | will not experience’an adverse side effect from the vaccine. I request that it be given tome. (Signature of Partonrecelving Vaccine) eoxr (Cate signed) DATE DUE DATEVACCINATED. LOT #EXP DATE ADMINISTERED BY Dose Dose #2 Dose #3 . Booster DECLINATION TO HEPATITIS B VACCINE understand that due to my occupational exposure to blood ‘Praneme) or other potentially Infectious materials | may be at risk of acquiring Hepatitis B Virus (HBV) infection. ‘have been given the opportunity to receive hepatitis B vaccine, at no charge to myself. However, | decline Hepatitis B vaccination at this time. | understand that by declining this vaccine, | continue to bbe at risk of acquiring Hepatitis B, a serious disease. ifin the future | continue to have occupational ‘exposure to blood or other potentially infectious materials and | want to be vaccinated with Hepatitis B vaccine, | can receive the vaccination series at no charge to me therefore | am declining it at this time. (Signature of Person decning Vaccine) or fl claim to have previously received eomivams) Hepatitis B Vaccine from (Print Name PerneniFactity/Oate Vaccine Received) State University of New York Downstate Medical Center 450 Clarkson Avenue, Box 33, Brookiyn, NY 11203-2098 » Phone 718 270-1995 / 1969 Fax718 270-2477