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Hepatitis B Vaccine Notification Form

Columbia University
Environmental Health and Safety
500 West 120th Street, MC 2215
S.W Mudd Buidling Suite 350
New York, NY 10027
Telephone: (212) 854-8751
Fax: (212) 316-4937
Mail Code: 2215
ehrs@columbia.edu

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 have declined the 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.

 

Yes, I wish to be vaccinated against Hepatitis B.

 

I have already received the Hepatitis B vaccine. Please review my status.

Please return completed form to your departmental office.

Name:   Social Security Number:
 

Department:
 

Campus Address:
 

Daytime Phone (8:30 am 5:00 pm):
 

Signature:______________________________________________ Date (mm/dd/yyyy):________________