SECTION 1 – Declination of Services
I understand that as part of my job duties I may be exposed to blood or other bodily fluids. I further acknowledge that if exposed, I may be at risk of acquiring a bloodborne pathogen such as hepatitis B (HBV), hepatitis C or HIV. I acknowledge that, in the course of my duties at VDOF, I have been exposed to blood or bodily fluids and have filed an accident report with exposure details; and, as a result of exposure, I may be at risk of acquiring a bloodborne disease. As per my report, VDOF has given me the opportunity to seek a medical examination for baseline testing of bloodborne pathogens and to receive a Hepatitis B vaccination at no charge. I am: I understand that by declining the vaccine I continue to be at risk of acquiaring hepatitis B, hepatitis C or HIV. Year:
Declining the examination/testing at this time
Declining the Hepatitis B vaccine at the time
I understand that by declining the HBV vaccine, I continue to be at risk of acquiring hepatitis B. Should I desire to receive the vaccine at a future date, however, I can still do so at no charge.
SECTION 2 – Signature
Affected Employee Name (Print)	Affected Employee Signature	Date