Policy Manual sample

MDT Home Health Care Agency, Inc. Name: ______________________________________ HEPATITIS B DECLARATION FORM* Hepatitis B is a major infectious occupational health hazard in the Health-Care industry. The critical risk for health personnel is contact with blood and other body fluids. Persons previously infected with hepatitis B virus are immune to the disease, for persons who have not had the disease, Hepatitis B it vaccine will provide immunity. The vaccine is given in three separate doses and failure to receive all doses may cause the vaccine to be ineffective and not result in immunity. Clinical studies have shown that 85 to 96 percent of those vaccinate evidence immunity. Periodic testing of vaccinated persons for antibody to Hepatitis B will confirm immune status. I understand that due to my risk or occupational exposure to blood or other potentially infectious material I may be at risk of acquiring Hepatitis B virus (HBV) infections, I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to my self. I have read the above information and have received verbal and written instructions regarding the efficacy, risk and complications of receiving the vaccine. Any questions I had have been answered. I acknowledge that I am aware of tine availability of tine Hepatitis B vaccine and the benefit that such vaccination provides in the prevention of infection with Hepatitis B virus. [ ] I decline Hepatitis B vaccination at this time because I have been previously immunized with a complete series (three injections) of the Hepatitis B vaccine or I have been diagnosed as having the Hepatitis B virus disease and I am immune. [ ] I decline Hepatitis B vaccination at this slate. I understand that by declining this vaccine, I continue to be at risk or acquiring Hepatitis B. If in the future I continue to have occupational exposure to blood or other potentially infectious material and I want to be Vaccinated with Hepatitis B vaccine, I may receive the vaccination series at no charge to me. (The DOH may have a list of free vaccination places) [ ] I accept vaccination with tine hepatitis B vaccine. _____________________________ __________________________ _______________ Employee Witness Date 1 st injection: __________ 2 nd : ______________ 3 rd ______________ * this is not a confidential form Home Health Agency Policies A-49