HEPATITIS B VACCINE DETERMINATION
I understand that due to my occupational exposure to blood and/or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I understand that upon exposure, I am to contact the office immediately and a confidential medical evaluation and follow- up will then be made available. Included in this medical evaluation will be the opportunity to receive the Hepatitis B Immune Globulin (HBIG) vaccination at no charge to me.
Please check box and insert your name next to ONE of the following:
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts shall be cause for dismissal if employed. My typed name below shall have the same force and effect as my written signature when submitted electronically.
Thank you! If you do not hear from us within 7 days, please call the office at (410) 761-7665 to make sure we received your application.