Hepatitis B Virus Certification
(Dentists, Dental Hygienists, Dental Assistants)
___________________________________________________________________
PRINT NAME
___________________
DATE
I understand that due to my occupational exposure to blood or other potentially infectious
materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) infection.
SIGN ONE OF THE FOUR STATEMENTS BELOW
1. I,
, have received the Hepatitis B
(SIGN)
vaccination
series on __________________at_______________________________________.
2. I,
, have had a Hepatitis B titer
(SIGN)
performed
on __________________at_______________________________________.
3. I,
, have not received the Hepatitis
(SIGN)
B vaccination series, but would be interested in doing so. I can receive the vaccination
series at a local health department, my private physician’s office or at no charge through
my employer.
4. I,
, decline the Hepatitis B
(SIGN)
vaccinations 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 a local health
department, my private physician’s office or at no charge through my employer.