Hepatitis B Vaccination Form

In compliance with OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030, Mason employees at risk of occupational exposure to blood or other potentially infectious materials are eligible to receive the Hepatitis B vaccination series, at no cost to them.

NOTE: The Hepatitis B vaccine became part of most standard childhood vaccination schedules in 1991; employees born in, or after, that year may have already received the vaccine. Also, beginning in July 2005, the Commonwealth of Virginia requires students be immunized against Hepatitis B (or show proof of positive immunity or declination) before matriculating. If in doubt, check your personal health record, or with Student Health Services, to determine if you have already received the Hepatitis B vaccination series.

ALL eligible employees must provide a response; either an acceptance or declination of services.
Date*
MM slash DD slash YYYY
Name (First, Last)*
Email*
G#*
Department*
Phone #*
I DECLINE the Hepatitis B Vaccination series.
(Possible reasons for declination may include previous vaccination, personal health status, or personal choice.)
- I DECLINE
I ACCEPT the Hepatitis B Vaccination series.
(The vaccine is given in 3-doses; initial, +1 month, +6 months. A post-vaccine blood titer is recommended, but not required, to confirm immunity after completion of series.)
- I ACCEPT
Declination
Please read the following statement and enter your initials below to continue. You may choose to accept the vaccine series instead by unchecking Decline above.

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 infection. I have been given the opportunity to be vaccinated with 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 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.
By entering my initials below, I confirm I have read and understand the above statement.*
If you have questions or require further assistance, please contact the Environmental Health & Safety Office at safety@gmu.edu or 703.993.8448.
Accept

Please answer the questions below to proceed.
Send the Hepatitis B authorization letter via:*
- Email
- Inter-Office Mail
Email*
Mail Stop #*
Check the Student Health Clinic location where you would like to receive the series:*
- SUB I, Rm 2300, Fairfax campus
- Colgan Hall, Rm 229, Science & Technology (Prince William) campus
- Founders Hall, Rm B102, Arlington Campus
NOTICE: If you fail to begin the vaccine series within 45 days of receiving authorization, you shall be deemed to have declined the vaccination. Contact EHS for re-authorization.
Electronic Signature

By clicking the submit button below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

If you decline to sign electronically, please complete the following steps:
Please download this form as a PDF by clicking here. Print, sign, and return the completed form to the Environmental Health & Safety Office, 4400 University Dr., MS 5E2, Fairfax, VA 22030.

George Mason University

Environmental Health & Safety

Hepatitis B Vaccination Form

Declination

Accept

Electronic Signature

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