403.03 E1 - Communicable Disease - Employees - Hepatitis B Vaccine
403.03 E1 - Communicable Disease - Employees - Hepatitis B VaccineThe Disease
Hepatitis B is a viral infection caused by the Hepatitis B virus (HBV) which causes death in 1-2% of
those infected. Most people with HBV recover completely, but approximately 5-10% become chronic
carriers of the virus. Most of these people have no symptoms, but can continue to transmit the disease
to others. Some may develop chronic active hepatitis and cirrhosis. HBV may be a causative factor in
the development of liver cancer. Immunization against HBV can prevent acute hepatitis and its
complications.
The Vaccine
The HBV vaccine is produced from yeast cells. It has been extensively tested for safety and
effectiveness in large scale clinical trials.
Approximately 90 percent of healthy people who receive two doses of the vaccine and a third dose as a
booster achieve high levels of surface antibody (anti-HBs) and protection against the virus. The HBV
vaccine is recommended for workers with potential for contact with blood or body fluids. Full
immunization requires three doses of the vaccine over a six-month period, although some persons may
not develop immunity even after three doses.
There is no evidence that the vaccine has ever caused Hepatitis B. However, persons who have been
infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis in spite of
immunization.
Dosage and Administration
The vaccine is given in three intramuscular doses in the deltoid muscle. Two initial doses are given one
month apart and the third dose is given six months after the first.
Possible Vaccine Side Effects
The incidence of side effects is very low. No serious side effects have been reported with the vaccine.
Ten to 20 percent of persons experience tenderness and redness at the site of injection and low grade
fever. Rash, nausea, joint pain, and mild fatigue have also been reported. The possibility exists that
other side effects may be identified with more extensive use.
HEPATITIS B VACCINE INFORMATION AND RECORD
CONSENT FORM OF HEPATITIS B VACCINATION
I have knowledge of Hepatitis B and the Hepatitis B vaccination. I have had an opportunity to ask
questions of a qualified nurse or physician and understand the benefits and risks of Hepatitis B
vaccination. I understand that I must have three doses of the vaccine to obtain immunity. However, as
with all medical treatment, there is no guarantee that I will become immune or that I will not experience
side effects from the vaccine. I give my consent to be vaccinated for Hepatitis B.
________________________________________________ ____________________
Signature of Employee (consent for Hepatitis B vaccination) Date
________________________________________________ ____________________
Signature of Witness Date
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REFUSAL FORM OF HEPATITIS B VACCINATION
I understand that due to my occupational exposure to blood or other potentially infectious materials I
may be at risk of acquiring the Hepatitis B virus infection. I have been given the opportunity to be
vaccinated with Hepatitis B vaccine at no charge to myself. However, I decline the Hepatitis B
vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring
Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other
potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive
the vaccination series at no charge to me.
_________________________________________________ _____________________
Signature of Employee (refusal for Hepatitis B vaccination) Date
__________________________________________________ ______________________
Signature of Witness Date
I refuse because I believe I have (check one)
________started the series ______completed the series
HEPATITIS B VACCINE INFORMATION AND RECORD
RELEASE FORM FOR HEPATITIS B MEDICAL INFORMATION
I hereby authorize _______________ (individual or organization holding Hepatitis B records and
address) to release to the South Tama County Community School District, my Hepatitis B vaccination
records for required employee records.
I hereby authorize release of my Hepatitis B status to a health care provider, in the event of an exposure
incident.
___________________________________________________ ____________________
Signature of Employee Date
___________________________________________________ ____________________
Signature of Witness Date
HEPATITIS B VACCINE INFORMATION AND RECORD
CONFIDENTIAL RECORD
___________________________________________ _____________________________
Employee Name (last, first, middle) Social Security No.
Job Title: _____________________________________________________________
Hepatitis B Vaccination Date Lot Number Site Administered by
1_________________________ __________ ___________ ________________
2_________________________ __________ ___________ ________________
3_________________________ __________ ___________ ________________
Additional Hepatitis B status information:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Post-exposure incident: (Date, time, circumstances, route under which exposure occurred)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Identification and documentation of source individual:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Source blood testing consent:
________________________________________________________________________________________
Description of employee's duties as related to the exposure incident:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Copy of information provided to health care professional evaluating an employee after an exposure
Incident:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Attach a copy of all results of examinations, medical testing, follow-up procedures, and health care
professional's written opinion.
Training Record: (date, time, instructor, location of training summary)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Approved: November 10, 2025
Reviewed: November 10, 2025
Revised: November 10, 2025