Hepatitis B Vaccination

OSHA requires that all health care workers at risk of acquiring Hepatitis B have the opportunity to receive the Hepatitis B vaccination by their employer. Professional Nursing Service will provide this opportunity to you as is appropriate based upon your response to the following:

My signature below certifies that I have been provided with general education materials regarding exposure to blood borne pathogens as required by OSHA regulations. Further, i understand that I will be provided appropriate training at my assigned workplace and will adhere to the procedures of the facilities to which I am assigned by PNS staffing.

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 Virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me, while on active assignment with PNS staffing.

First Name:        Middle Initial:
Last Name:

Choose the appropriate response from the options below; sign and date where indicated.
Select One: I ACCEPT the hepatitis B vaccine

  I HAVE COMPLETED the vaccination series on:
First Vaccine: Date:       Hospital:       RN:
Second Vaccine: Date:       Hospital:       RN:
Third Vaccine: Date:       Hospital:       RN:

  I DECLINE the Hepatitis B vaccine series. 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 infectious materials and I want to be vaccinated with the Hepatitis B vaccine I can receive the vaccination series at no charge to myself, while on assignment with PNS Staffing. I accept the responsibility to inform PNS staffing of this decision at that time
  The information I have given is true and accurate.
Date: