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Hepa B Vaccine Consent Form

This document is a consent/refusal form for the Hepatitis B vaccine for students at Olivarez College Tagaytay. It outlines that students must receive two doses of the vaccine within a 6 month period to achieve protection. It notes some contraindications for receiving the vaccine including allergies to yeast or vaccine components, previous allergic reactions, illness, pregnancy, or planning pregnancy. It states the vaccine is being offered due to potential occupational exposure risk and is only part of safe job performance protection. Students agree to complete the series if they do not finish school. The refusal section notes the risk of HBV from occupational exposure but the student declines the vaccine at this time and understands the risk of acquiring Hepatitis

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KESLEY DELOS SANTOS
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315 views2 pages

Hepa B Vaccine Consent Form

This document is a consent/refusal form for the Hepatitis B vaccine for students at Olivarez College Tagaytay. It outlines that students must receive two doses of the vaccine within a 6 month period to achieve protection. It notes some contraindications for receiving the vaccine including allergies to yeast or vaccine components, previous allergic reactions, illness, pregnancy, or planning pregnancy. It states the vaccine is being offered due to potential occupational exposure risk and is only part of safe job performance protection. Students agree to complete the series if they do not finish school. The refusal section notes the risk of HBV from occupational exposure but the student declines the vaccine at this time and understands the risk of acquiring Hepatitis

Uploaded by

KESLEY DELOS SANTOS
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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OLIVAREZ COLLEGE TAGAYTAY

E.Aguinaldo Hi-Way, Brgy.San Jose, Tagaytay City

Hepatitis B Vaccine
Consent/Refusal Form

____Consent

I understand that I must receive 2 doses of the vaccine during a 6-month period,
at the scheduled dates, in order to achieve maximum protection. However, as with all
vaccines, there is no guarantee that I will become immune to Hepatitis B or that I will not
experience side effects. I understand that I should NOT receive this vaccine
if:
1.I am allergic to yeast (e.g. bread) or any other component of the vaccine. I
should tell my doctor if I have any severe allergies;
2.I have had an allergic reaction to a previous dose of Hepatitis B vaccine;
3.I am moderately or severely ill at the time the vaccine is scheduled
(e.g., I have a fever or I am immunocompromised).
4.I am pregnant, planning a pregnancy, or breastfeeding during the course of the
Hepatitis B vaccine. If I become pregnant while receiving the vaccination series, I
will notify both my obstetrician and my occupational care provider and
discontinue vaccination.
I understand that the Hepatitis B vaccine is being offered due to the potential
risk of occupational exposure to HBV, and that the injections are being administered for
a job-related reason and not for the purpose of providing general health care. This
vaccine is only part of the protection needed for safe job performance.
I understand that if I stop studying before completing the series, the
School is not obligated to provide future vaccines. I understand that it is my
responsibility, and I agree to make arrangements to complete the series with
inoculations at 1 and 6 months after the initial dose.

_____________________________ _____________________________
Signature over Printed Name of Student Signature over Printed Name of Guardian
____Refusal

I understand that, due to my risk for 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 the Hepatitis B
vaccine at no charge to myself. However, I decline 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 want to be vaccinated with the Hepatitis
B vaccine, I can receive the vaccination series at no charge to me. I have read the
Hepatitis B Vaccine Information Statement and have had the opportunity to ask
questions and understand the benefits and risks of the Hepatitis B vaccination. I do not
wish to receive the Hepatitis B vaccine and decline vaccination.

_____________________________ _____________________________
Signature over Printed Name of Student Signature over Printed Name of Guardian

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