EMT Program Communicable Diseases Hepatitis B Vaccine Acknowledgement and Release Form

I hereby acknowledge that I have received and reviewed the information provided regarding communicable diseases including Hepatitis B and HIV. I understand that I assume the risk of infection from communicable diseases, including Hepatitis B and HIV (AIDS) from my clinical experience.


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EMT Program Communicable Diseases Hepatitis B Vaccine Acknowledgement and Release Form

I have received information and have had my questions answered about the Hepatitis B vaccine. I understand that receiving the vaccine is highly recommended, but not required, for persons such as health care workers who have contact with blood/bloody secretions.

I also understand that, should I elect to receive the Hepatitis B vaccine, it is MY RESPONSIBILITY to pay the cost of the series of three (3) injections required. I understand that all medical bills associated with contracting a communicable disease during my clinical education are my responsibility and Delta College has no obligation to pay my medical expenses.

I hereby release Delta College, its employees, teaching affiliates, and members of its Board of Trustees from any and all claims and actions for personal injury or death resulting from communicable diseases contracted while a student at Delta College, whether arising out of clinical experience or otherwise.

PLEASE CHECK ONE OF THE FOLLOWING:

I HAVE ALREADY RECEIVED THE HEPATITIS B VACCINE AND VERIFICATION IS ATTACHED.
I AM IN THE PROCESS OF GETTING THE VACCINE
I DECLINE THE HEPATITIS B VACCINE AND RELEASE DELTA COLLEGE FROM LIABILITY SHOULD I BECOME INFECTED WITH HEPATITIS B.

STUDENT’S NAME (PRINT)

STUDENT’S SIGNATURE

PROGRAM

DATE

Source: https://www.delta.edu/programs/fire-science/_documents/hep-b-release.pdf