Hepatitis B Vaccination Declination Name: ______________________________________________ School: ___________________________ Address: ______________________________ Country: ______________ State: _____ Zip: _________ USC ID #: _____________________________
Telephone Number: _________________________
I, _________________________________, decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk for acquiring Hepatitis B, a serious disease. I have been given the opportunity to ask questions, and those questions have been answered and I understand the program. I also understand that USC Student Health strongly urges and recommends I receive the vaccine. I decline the Hepatitis B vaccination series. I have already received the Hepatitis B vaccination series. I have religious objections to being vaccinated. I do not believe I have a risk of acquiring Hepatitis B. I fear possible side effects of the vaccine. Other: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ______________________________________________
_______________________
______________________________________________
_______________________
Authorized By: ______________________________________
_______________________
Signature Witness
Signature
Date
Date
Date
1031 West 34th Street, Los Angeles, California 90089-3261 ∙ (213) 740-9355 IMM_HEPBDEC_031623_F