CNM Hepatitis B Vaccination Request Form
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.
I request the Hepatitis B-Vaccination .
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Employee Supervisor Witness
Print Print
_________________________________ _____________________________ (Employee Sign and date) (Supervisor Sign and date)
[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996]
