Hepatitis B Vaccination | JCTC

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Hepatitis B Vaccination

Hepatitis B Vaccination I Declination Form

This form must be signed and submitted to your instructor. 

  • I understand that as a student enrolled in the Jefferson Community and Technical College, I may be exposed to infectious diseases and/or blood-borne pathogens, such as the Hepatitis B virus.
    • I further understand that as a result of this exposure, I may acquire the Hepatitis B virus or another infectious disease.
    • Jefferson Community and Technical College strongly recommends that students in healthcare programs receive the Hepatitis B Vaccination.
  • Even though I have been informed of the potential risk, I decline to receive the vaccination at this time.
    • I realize that by declining to have the Vaccination, my clinical experiences may be limited and/or refused.
    • Jefferson Community and Technical College does not accept any responsibility for this because the immunization policy is a requirement of the affiliating clinical agencies and not that of the College.
  • I further understand that without the immunization, I remain at risk for acquiring the disease for which the immunization is indicated.
    • Jefferson Community and Technical College will not assume any cost or charges if I decide to receive the immunization now or in the future.
  • I have read & understand the above information and decline the Hepatitis B Vaccination series.
  • I have completed the Hepatitis B Vaccination series; therefore, this form does not apply to me.
  • I have started receiving the series (3 doses) of Hepatitis B Vaccination and will submit a copy for my student file of each subsequent vaccination series as it is administered. 

Student's Name (Printed):

Student's Signature: