Get Hep B Declination Form

Vaqta, (hepatitis A vaccine inactivated) dosing, indications, interactions, adverse effects, and more.

(NHJB-2123-P) Form use. This form is used if the person who is named in the will to serve as the executor of an estate or trustee of a testamentary trust does not wish to serve. A declination may not be filed if there are no estate assets.

Employers must ensure that workers who decline vaccination sign a declination form. The purpose of this is to encourage greater participation in the vaccination program by stating that a worker declin- ing the vaccination remains at risk of acquiring hepatitis B.

DECLINATION: I understand that due to my occupational exposure to blood or other poten tially infectious materials that I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine.

The most common reason for refusal was “my baby is too young” (78.1%), followed by “I don't think my child is at risk for hepatitis B” (43.8%). “Concerns regarding the safety of the vaccine” was the most common answer given for why participants refused vaccination (70.4%).

(NHJB-2123-P) Form use. This form is used if the person who is named in the will to serve as the executor of an estate or trustee of a testamentary trust does not wish to serve. A declination may not be filed if there are no estate assets.

Hepatitis A vaccine is administered by injection into the muscle of the upper arm. Two separate shots of 0.5 ml for children and 1 ml for adults are required and should be given 6 to 12 months apart () or 6 to 18 months apart (Vaqta).

Declination (Statement of Non-Participation) 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 (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself.