Instructions: This form fulfills OSHA’s Bloodborne Pathogen Standards requirement for Hepatitis B vaccination. Complete each section and submit the completed form along with any accompanying vaccination records to Employee Health Services.

part i: vaccination applicability
Vaccination is applicable Vaccination is not applicable
part ii: vaccination review or declination
Vaccine Review I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring infection and may require vaccination for Hepatitis B: Vaccination received through Emory’s Employee Health Services Vaccination was received from outside source - provide proof of vaccination, e.g., location, date
Employee Printed Name	Employee ID #
Employee Signature	Date
Vaccine is Declined 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 Printed Name	Employee ID #
Employee Signature	Date
part iii: form submission
Completed Hepatitis B – Immunization Review and Declination Forms will be filed in medical records. Submit your form to Employee Health Services by either:
or Hand Delivery: Emory University Hospital - 2nd floor, D219 Emory University Hospital Midtown - WW Orr 6th floor	Fax: 404-686-1527