ࡱ> LNKO  8bjbjUU 4<7׎e7׎e 0 0 uuuuu8l-$~"Q-===!!!!!!!$z$0'!]uggg!uu==8" gFu=u=! g! =a{OR !N"0~" 'z' 'u 0H" j!!yt~"gggg'0 ;: University of Montana Hepatitis B Vaccination Employee Faculty/Staff Member:  FORMTEXT       Griz Card #:  FORMTEXT       Department:  FORMTEXT       Work Phone:  FORMTEXT       Supervisor:  FORMTEXT       CHOOSE EITHER OPTION 1 OR OPTION 2: OPTION 1: If you are an employee with occupational exposure to human blood, fluids or tissues and you elect to receive hepatitis B vaccination at Curry Health Center (Lori Simkins, 243-2873), sign the vaccine request and give to your immediate supervisor for a charge-back number. Once vaccinated, give confirmation of vaccination and subsequent titers to your supervisor. Vaccination Request I have read and understand the ϻ Bloodborne Pathogens Exposure Control Plan,  HYPERLINK "http://www.umt.edu/research/Compliance/IBC/BBP.php" www.umt.edu/research/Compliance/IBC/BBP.php, and have been trained about the hazards of bloodborne pathogens. I understand that due to my occupational exposure to human blood, fluids or tissues, I may be at risk of acquiring hepatitis B virus (HBV) infection. I elect to receive the hepatitis B vaccination series (3 injections over 6 months) at this time and at no cost to me. Signature of Employee Date:  FORMTEXT       OPTION 2: If you are an employee with occupational exposure to human blood, fluids or tissues and (A) elect NOT to receive the hepatitis B vaccine, or (B) if you have been previously vaccinated, please sign below and give to your immediate supervisor. A. Hepatitis B Vaccination Declination I understand that due to my occupational exposure to human blood, fluids or tissues I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. H*,BDZ^`prv²}kZ?(,hY hez5B*CJOJQJ^JaJph5jhY hez5B*CJOJQJU^JaJph hezh^VCJOJQJ^JaJ#h)$h)$5CJOJQJ^JaJh#5CJOJQJ^JaJ#hvh)$5CJOJQJ^JaJ&hL-h)$5>*CJOJQJ^JaJhL-h!5>*OJQJ^Jh'l5OJQJ^Jh!5OJQJ^Jh)$5OJQJ^Jhvh)$5OJQJ^Jhvh)$aJ h)$aJ,^`rtv P    L]^LgdOgd)$ L^LgdO <gd)$ L<^LgdL- Lx^LgdL-gd)$$a$gd)$ $x^a$gd'l $ & ( < > L f h j ~ ƴ|^Ƣ|@Ƣ|;jhY hez5B*CJOJQJU^JaJph;jthY hez5B*CJOJQJU^JaJph,hY hez5B*CJOJQJ^JaJphhez5CJOJQJ^JaJ#hezh)$5CJOJQJ^JaJ#h)$h)$5CJOJQJ^JaJ5jhY hez5B*CJOJQJU^JaJph;jhY hez5B*CJOJQJU^JaJph~  ƴ~`SE1&h)$h)$56CJOJQJ^JaJh)$h)$>*OJQJ^Jhezh)$OJQJ^J;jhY hez5B*CJOJQJU^JaJph,hY hez5B*CJOJQJ^JaJphhezCJOJQJ^JaJ hezh)$CJOJQJ^JaJ#hezh)$5CJOJQJ^JaJ5jhY hez5B*CJOJQJU^JaJph;j\hY hez5B*CJOJQJU^JaJph    & * 2 p s w }  ) + ͹ͫͫ͌~pb~bp~TThU^CJOJQJ^JaJhoKCJOJQJ^JaJh^CJOJQJ^JaJhcCJOJQJ^JaJhaCJOJQJ^JaJ hvh)$CJOJQJ^JaJh)$CJOJQJ^JaJ&hL-h!5>*CJOJQJ^JaJh!CJOJQJ^JaJ&h)$h)$5>*CJOJQJ^JaJ h)$h)$CJOJQJ^JaJ  1)wh[$\$^hgdO$a$gdO$a$gd)$$  @ P !L^La$gdOgd)$L&d P ]^LgdO  P #gdL-  gdL-L]^LgdL- ]gdL- , - X Y ɸɧ}oZIZ6Z$hOhL-0JCJOJQJ^JaJ hOhL-CJOJQJ^JaJ)jhOhL-CJOJQJU^JaJhL-CJOJQJ^JaJhu"WCJOJQJ^JaJhOCJOJQJ^JaJh)$CJOJQJ^JaJ hvh)$CJOJQJ^JaJ hN!5>*CJOJQJ^JaJ&hvh)$5>*CJOJQJ^JaJ#hvh)$5CJOJQJ^JaJ hvhN!CJOJQJ^JaJY Z _ ] b c i Ϳ͇ͣͣufXF#hvh)$>*CJOJQJ^JaJhZmCJOJQJ^JaJhq>*CJOJQJ^JaJ#h/Fh)$>*CJOJQJ^JaJhaCJOJQJ^JaJh$FCJOJQJ^JaJhN!CJOJQJ^JaJh!CJOJQJ^JaJh)$CJOJQJ^JaJ hvh)$CJOJQJ^JaJ hOh)$CJOJQJ^JaJ hOhu"WCJOJQJ^JaJ $&*0בrdRC1#hvh)$5CJOJQJ^JaJh)$>*CJOJQJ^JaJ#hvh)$>*CJOJQJ^JaJh)$CJOJQJ^JaJ h~JhOCJOJQJ^JaJh~JCJOJQJ^JaJ hvh)$CJOJQJ^JaJ;jDhY hez5B*CJOJQJU^JaJph,hY hez5B*CJOJQJ^JaJph5jhY hez5B*CJOJQJU^JaJphhezCJOJQJ^JaJ0FVX ,>DLn  Ͻ𮟮||m\Mha>*CJOJQJ^JaJ hvh)$CJOJQJ^JaJhU^5CJOJQJ^JaJ hL-h)$CJOJQJ^JaJ#hvh)$5CJOJQJ^JaJhZm5CJOJQJ^JaJh)$5CJOJQJ^JaJ#hN!hN!5CJOJQJ^JaJhN!5CJOJQJ^JaJ#hL-h!>*CJOJQJ^JaJh!5CJOJQJ^JaJ $%01flq,(()a)~)))))))))Ϻ}l[M?h!CJOJQJ^JaJhZmCJOJQJ^JaJ hvhZmCJOJQJ^JaJ hvhOCJOJQJ^JaJh)$CJOJQJ^JaJh$FCJOJQJ^JaJUhN!CJOJQJ^JaJ hqhqCJOJQJ^JaJ)hvh)$5>*䴳ϴ^*<>*CJOJQJ^JaJhN!>*CJOJQJ^JaJ#hvh)$>*CJOJQJ^JaJowever, I decline 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 human blood, fluids or tissues and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series (3 injections over 6 months) at no cost to me. Signature of Employee Date:  FORMTEXT       B. 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