I understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B Vaccine at no charge to myself. I have also been asked if I have questions regarding this information and if I had questions, they were fully answered to my satisfaction.

I , decline the Hepatits vaccine at this time. I understand that by declining this vaccine, I continue to be at risk for acquiring Hepatitis B, a serious disease. If in the future, while employed by Blossom Home Care, LLC I continue to have occupational exposure to blood or other potentially infectious material and I want to be vaccinated I can receive the vaccination series at no charge to myself.