Hepatitis B Vaccination Declination/Verification Form

The OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030 requires that the Hepatitis B vaccination series be made available to employees that have potential occupational exposure to the Hepatitis B virus. Per this standard, FIU is required to maintain documentation of offering the vaccine to employees and completion of the vaccine by employees. Please complete this form to verify completion of the Hepatitis B vaccination series or to complete the declination statement for the vaccination series.

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Date Date / MM / DD YYYY
Name Name First Last
Email
Please select one of the options below.

Please select one of the options below. I completed the Hepatitis B vaccination I would like to decline the offer to complete the Hepatitis B vaccination series