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I understand that due to my occupational exposure to blood and/or other potentially infectious materials, I may be at risk of acquiring Hepatitis B (HBV) infection. 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 been given the opportunity to be vaccinated with the Hepatitis B vaccination series at no charge to myself with a proof of negative titer.
I decline the series because I can provide a positive titer that I can submit within 10 years.
I decline the Hepatitis B vaccination series at this time. I do understand that by declining the vaccination series, I continue to be at risk of acquiring Hepatitis B, a serious disease.

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