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HEPATITIS B VACCINATION FORMS A, B, &C <br /> IN ACCORDANCE WITH OSHA STANDARDS, ALL MEMBERS OF THE FALCON HEIGHTS <br /> FIRE DEPARTMENT ARE REQUIRED TO COMPLETE ONE OF THE THREE FORMS <br /> LISTED BELOW. THE COMPLETED FORM MUST BE SUBMITTED TO THE ONE OF THE <br /> RESCUE CAPTAINS <br /> HEPATITIS B VACCINATION DATA <br /> FORM A <br /> I have received the Hepatitis B vaccinations series. The dates of the vaccinations and the medical <br /> provider are as follows: <br /> Vaccination Dates #1 #2 #3 <br /> Medical Provider: <br /> Signature Date: <br /> Print Name <br /> HEPATITIS B VACCINATION DATA <br /> FORM B <br /> (Please check) I would like to be vaccinated against Hepatitis B at the expense of the <br /> Falcon Heights Fire Department. <br /> Signature Date: <br /> Print name: <br /> HEPATITIS B VACCINATION DATA <br /> FORM C <br /> I understand that due to me occupational exposure to blood or other potentially infectious materials <br /> I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity <br /> to be vaccinated with hepatitis B vaccine at no charge to myself. <br /> However, I decline Hepatitis B vaccination at this time. I understand that by declining this <br /> vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I <br /> continue to have occupational exposure to blood or other potentially infectious material and I want <br /> to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to <br /> me. <br /> Signature Date <br /> Print Name <br /> 16 <br />