Hepatitis B Vaccination Acceptance/Declination Form

In accordance with the OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030, George Mason University employees at risk of occupational exposure to blood or other potentially infectious materials are eligible to receive the Hepatitis B vaccination series. All employees determined to be at risk MUST complete this vaccine acceptance/declination form below as part of their annual training.

NOTE: Possible reasons for declining the Hepatitis B vaccine may include previous vaccination for Hepatitis B, personal health status, or personal choice. You do not need to provide a reason for declining the vaccine, and if you initially decline, you may change your mind at any time by contacting Employee Health and Wellness EHW@gmu.edu

Hepatitis B Vaccine Acceptance/Declination Form

Name(Required)

First Last

Email(Required)

G#(Required)

Please select one of the following options:(Required)

I ACCEPT the Hepatitis B vaccination series.

I DECLINE the Hepatitis B vaccination series.

I have previously submitted this form and do not wish to change my response at this time.

Before submitting your response, please read below:

The vaccine is given in 2-doses; initial & +1 month. I understand that I will be contacted by someone from Student Health Services to schedule a vaccine appointment, and that it is my responsibility to keep the appointment or to reschedule if I am unable to make my appointment. If I fail to begin the vaccine series within 45 days of receiving authorization, or fail to complete the vaccine series, I shall be deemed to have declined the vaccination. If I decide I still want to receive the vaccination after 45 days, I will contact Employee Health & Well-Being for re-authorization.

Before submitting your response, please read below:

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 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.