Hepatitis B Vaccination or Declination

Vaccination against the Hepatitis B virus (HBV) is provided free of charge to University of Utah employees (including graduate students) who have exposure to human blood, blood products, certain human body fluids, tissues, organs, and primary cell lines. The HBV vaccination is a series of 3 shots given over a period of 6 months (0, 1-2, 4-6 months).

I understand that due to my occupational exposure to blood or other potentially infectious materials (OPIM) I may be at risk of acquiring Hepatitis B virus (HBV) infection.

By signing this form, I certify that I have been given the opportunity to be vaccinated against the Hepatitis B virus at no charge to myself. I understand that if I decline 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 the Hepatitis B vaccine, I can receive the vaccination series at no charge to me by contacting Environmental Health and Safety to make the necessary arrangements.

Hepatitis B Vaccination or Declination

Contact Information

Sending