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
- I have completed the Hepatitis B Vaccination series; therefore, this form does not
apply to me.
- I have started recelvinq 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):