Hepatitis B Vaccination Request Form


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, at no charge to myself.

I request the Hepatitis B-Vaccination.

Employee (Print)

Supervisor/Witness    (Print)

Employee  (Sign and date)

Supervisor (Sign and date)

Pertinent federal regulations include: 56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996