Hepatitis B Vaccination

OSHA requires all health care workers, at risk of acquiring Hepatitis B, be allowed to receive the Hepatitis B vaccination by their employer. Professional Nursing Service will provide this opportunity to you based upon your responses to the following. Your signature below certifies that you have been provided with general educational materials regarding exposure to bloodborne pathogens, as required by OSHA regulations. Furthermore, you understand that you will be provided appropriate training at your assigned workplace facility, and will adhere to the policies and procedures of those facilities. You understand that due to the exposure of blood and/or other potentially infectious materials while performing your job duties, you may be at risk of acquiring Hepatitis B. You have been allowed to be vaccinated with the Hepatitis B vaccine, at no cost to you, while on active assignment with PNS. Choose the appropriate response from the options below; sign date where indicated.
Name
Checkboxes
I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B. If in the future I continue to have occupational exposure to blood or other infectious materials and want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to myself, while on assignment with Professional Nursing Service. I accept responsibility to inform PNS of this decision at that time.
Drop files here or
Max. file size: 512 MB.
    If you have completed the Hepatitis B Series, or have a Hepatitis B titer, please upload a copy of your medical records here.
    MM slash DD slash YYYY
    Your signature above certifies that you have been provided with general educational materials regarding exposure to bloodborne pathogens, as required by OSHA regulations. Furthermore, you understand that you will be provided appropriate training at your assigned workplace facility, and will adhere to the policies and procedures of those facilities. You understand that due to the exposure of blood and/or other potentially infectious materials while performing your job duties, you may be at risk of acquiring Hepatitis B. You have been allowed to be vaccinated with the Hepatitis B vaccine, at no cost to you, while on active assignment with PNS.