Form G: Informed Consent

Confidential

INFORMED CONSENT FOR HEPATITIS B VACCINATION

(For employees and independent contractors)

I, __________________________________, hereby authorize my employer to vaccinate me against Hepatitis B virus (HBV). I understand that the injections are given over a period of several months before it is effective in preventing this disease.

I have been informed of occasional side effects resulting from HBV immunization which include, but are not limited to, pain, itching, bruising at the injection site, sweating, weakness, chills, blushing and tingling, as well as other side effects, warnings and contraindications noted in The Physician's Desk Reference and manufacturer's information sheets.

I have been informed that hypersensitivity to yeast is a contraindication for use of the vaccine; that the vaccine should be administered to a pregnant woman only if clearly needed, and to nursing mothers with caution.

All my questions have been answered to my satisfaction. I believe that I have adequate knowledge upon which to base an informed consent to the vaccination. I acknowledge that no guarantees have been made to me concerning the results of the proposed vaccination. I hereby release my employer from any and all liabilities and legal responsibilities as a consequence of my decision to receive this vaccine.

I have contacted my personal physician and he/she has given me permission to receive the vaccine, based on my previous medical history.


Signature __________________________________________

Date___________

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Program Coordinator's Notation:

This employee has agreed to receive vaccination against Hepatitis B. The vaccination series will be provided at no cost to the employee by this educational facility.

Signature of Program Coordinator_____________________ Date _______

Note: Maintain this record for the duration of employment plus 30 years.