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Hepatitis B Vaccine Consent / Declination Form Your position is in the “high risk” category due to your potential occupational exposure to blood or other potentially infectious materials, which could put you at risk of acquiring Hepatitis B virus (HBV) infection. The Center for Disease Control recommends that any worker at risk for exposure to contaminated blood and/or body fluids, which you may be during the course of your job, should be vaccinated against Hepatitis B. The City of Woodburn is providing you with the opportunity to be vaccinated with the Hepatitis B vaccine at no cost to you. Please choose one of the following options: Consent Declination Employee Signature: Date: Printed Name: If Employee is under 18 years of age Parent/Guardian Signature: Date: Printed Name: I am choosing not to receive the vaccine at this time because I already received the vaccine series. I am choosing not to receive the vaccine series at this time. I understand that by declining this vaccine, I continue to have a risk of exposure to and acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposures 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 cost to me. I am aware that if I am interested in receiving this series of shots I need to contact Human Resources for further instruction. I consent to receiving Hepatitis B Vaccination(s) through the City of Woodburn's no- cost program. I have already received the Hepatitis B Vaccine, but would like to be Titer tested to determine the vaccine’s continued efficacy. Based on Titer testing results, doctor may recommend the following, check all that you consent to: If efficacy is still in place, no additional vaccine or vaccine booster is needed and I am declining further vaccine. If booster is needed, I consent to getting the HBV booster. If vaccine series needs to be repeated, I consent to having the HBV series. SIGN SIGN