7.14

NORTHWESTERN UNIVERSITY

HEPATITIS B VACCINATION CONSENT/WAIVER FORM

Name (Please Print):______________________________________________________

Date of Birth:_______/_______/_______

Social Security Number:________-________-_________

A. Consent for Hepatitis B Vaccine

I,

_______________________________________

consent to be immunized against hepatitis B. I acknowledge the following.

1. I have been informed that I am at risk of acquiring hepatitis B because of the nature of my professional responsibilities.
2. I have read the information sheet that lists the indications, benefits, and presently known side effects of hepatitis B vaccine, have had an opportunity to ask questions, and have had them answered to my satisfaction.
3. I must receive three (3) doses of vaccine over a period of six (6) months to confer optimal immunity.
4. I understand, however, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse reaction to the vaccine.
5. In the event that I experience any adverse side effects or do not become immune from the vaccine I hereby hold Northwestern University harmless from any and all liability to the extent permitted under the law.
6. In the event that I should terminate employment at Northwestern University prior to receiving all three (3) doses of hepatitis B vaccine, I understand that it will be my responsibility to complete the vaccination series on my own initiative and at my own expense.

____________________________ _______________________ ___________________

Employee Signature

Department

Date

Are you currently pregnant or breast feeding? Yes______No______.

Dose/site/Lot#/Initials:

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B. Previous Immunization with Hepatitis B Vaccine

I,_______________________________________________, have previously completed a three-dose series of

the Hepatitis B Vaccine at _______________________________ in 19________ .

____________________________ _______________________ ___________________

Employee Signature

Department

Date

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C. Refusal to Receive Hepatitis B Vaccine

I, _____________________________________________, understand that due to my occupational exposure to blood 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 myself. However, I decline hepatitis B vaccination at this time. 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 potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

____________________________ _______________________ ___________________

Employee Signature

Department

Date