Declination Form for Hepatitis B Vaccination

Policy Code: 
JHC-E
Adoption Date: 
Wednesday, November 18th, 1992

DECLINATION FORM FOR HEPATITIS B VACCINATION 

I, ____________________________ , have read the Iron School District Bloodborne

                      print name

Pathogens regulation (JHC-R2) and understand that under this policy I am entitled to a hepatitis B vaccination.  I understand that the vaccination is provided by the Iron District free of charge and should be done prior to my job exposing me to any risk of disease from blood borne pathogens.  By signing in the space provided at the bottom of this form, I hereby choose not to have the hepatitis B vaccination at this time.  I understand that I may change my mind and receive the vaccination at a later date if my job duties put me at a greater risk.

 

_________________________________                    ________/________/________

                Signature of employee                                                              Date

 

 

_________________________________                     ________/________/________

                    Superintendent                                                                    Date

 

Contents

Non-Discrimination Statement

Iron County School District is committed to a policy of equal employment opportunity and does not discriminate in the terms, conditions, or privileges of employment on account of race, age, color, sex, national origin, physical or mental disability, or religion or otherwise as may be prohibited by federal and state law.

School District Office

Hours 8 a.m. - 5 p.m. Mon.- Fri.
Address:
2077 W. Royal Hunte Dr.
Cedar City, Utah 84720
PH 435.586.2804  FAX 435.586.2815