Hepatitis B Vaccination Consent Form Template

In BC, OHS laws require employers to offer workers who are exposed to the risk of contracting Hepatitis B at work the opportunity to receive a vaccination against that virus at the company’s expense, along with information about Hepatitis B and the vaccine. Although it currently applies to Hepatitis B, the BC OHS requirement could be expanded to other pathogens. Moreover, offering free vaccination against occupational exposure to particular pathogens may be either recommended or required under medical protocols and federal licensing requirements. Here’s a template form you can adapt to document that you offered the vaccine and got the worker’s consent to receive it.

Worker’s Consent to Hepatitis B Vaccine

On      (Date)          , I                            (Worker’s Name)                                       received information from ABC Company concerning the risk of occupational exposure to blood or other potentially infectious materials in the position of   (Job Title) , which has been determined as job classification exposure Category  (I or II). I have received a copy of the Hepatitis B information packet which has been explained to me and I understand this information.

Specifically, I have been informed and understand:

(1) That the Hepatitis B vaccination may reduce the potential risk of occupationally contracted viral hepatitis infection;

(2) The risks of the Hepatitis B vaccination which may include pain, itching, bruising at the injection site, sweating, weakness, chills, flushing, and tingling;

(3) That to obtain adequate immunity to viral Hepatitis B, it will be necessary to receive all three vaccinations of the vaccine series which are administered one month and six months after the initial vaccination;

(4) That the vaccination will be provided to me free of charge by ABC Company;

(5) That if at such future time, the (province) Centre for Disease Control recommends a booster dose(s) of Hepatitis B vaccine, such booster dose(s) shall also be provided to me at no cost if I am employed by ABC Company in a job classification that involves some risk of an occupational exposure to blood or other potentially infectious materials; and

(6) That if I leave the employment of ABC Company before the series is completed, it is my responsibility to contact my own medical provider to complete the vaccine series.

I hereby consent to the administration of the Hepatitis B vaccination and voluntarily acknowledge that:

I do not have an allergy to yeast.

I am not pregnant or nursing.

I am not planning to become pregnant within the next six months.

I have not had a fever, gastric symptoms, respiratory symptoms, or other signs of illness in the last 48 hours.

I do have the following known allergies:

Food:

Drugs:

Other:

You may wish to consult with your physician before taking the vaccine.

 

(Worker Name and Identification Number)                                                 (Date)

 

(Witness)                                                                                 (Date)

(PLACE IN WORKER’S MEDICAL FILE)