CC RES 92-020 RESOLUTION AUTHORIZING THE MAYOR AND CITY MANAGER TO EXECUTE AN AGREEMENT BETWEEN THE CITY OF ST. ANTHONY AND THE CITY OF BLOOMINGTON FOR PROVISION OF HEPATITIS B VACCINE

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Exhibit A • CITY OF ST. ANTHONY HEPATITIS B VACCINE CONSENT/REFUSAL FORM I have read the policy statement and the information sheet about Hepatitis B and the Hepatitis B vaccine. I have had a chance to ask questions. I have all the information I desire and understand the benefits, risks and possible adverse effects consenting to or refusing the Hepatitis vaccination. I accept those risks. I understand that if I consent to the vaccination I must have three separate vaccinations. I understand it is my responsibility to receive the doses according to the schedule. I further understand that the vaccine has been offered to me at no cost. I wish to receive the Hepatitis vaccinations. Signature Date 1 prefer not to receive the Hepatitis B vaccine and decline the opportunity to be vaccinated. I do understand that I may receive the vaccination series in the future at my request. Signature Date PLEASE RETURN TO THE CITY CLERK