Hepatitis B Vaccine Information and Consent Form

Hepatitis B vaccine is available free of charge to employees through the U-M Occupational Health Services (U-M OHS). The following information describes the risk of acquiring Hepatitis B and the side effects of the vaccine.

Hepatitis B:

Hepatitis B virus causes inflammation of the liver. Symptoms may include jaundice (yellow skin), nausea, loss of appetite, fatigue and weakness. About 10% of infected people will develop chronic hepatitis, which can lead to cirrhosis and, infrequently, the acute illness can be fatal. The time from infection to symptoms is 2-5 months.

Hepatitis B virus is found in blood and many other body fluids. The infection is spread through sexual contact or by blood or other fluids of an infected person coming into contact with blood or mucous membranes (eyes and mouth) of another person.

Immunization:

Hepatitis B vaccine is recommended for all persons who are at increased risk of infection with Hepatitis B virus, including health care workers who may be exposed to blood or body substances. Hepatitis B vaccine does not contain human serum and cannot transmit any infection. One cannot develop hepatitis, AIDS or any other viral illness from receiving the vaccine. After a series of 3 doses of the vaccine injected into the upper arm over 6 months, about 90% of healthy adults develop antibodies which protect against development of Hepatitis B. This protection is long lasting so boosters are not routinely recommended.

Side Effects:

Among recipients of Hepatitis B virus vaccine, soreness and redness at the injection site have occasionally been seen. Flu-like symptoms and low grade fever are rare. Other side effects have been reported; however, they do not occur at a rate higher than in the general, unvaccinated population. Hypersensitivity has not been reported. Safety of the vaccine for the developing fetus is not known, but because it is non-infectious, the risk to the fetus from the vaccine should be negligible. However, Hepatitis B infection (which can be prevented by this vaccination) in a pregnant woman may result in severe disease for the newborn. If you are pregnant, we recommend discussing all vaccines and medications with your health provider.

Immune Status and Current State of Health

Because it is unnecessary, the vaccine is not recommended for persons with immunity to Hepatitis B.

Have you ever been told that you had Hepatitis B?

YES________ NO__________

Explain:_____________________________________________________________

Have you ever received the Hepatitis B vaccination?

YES________ NO________

Do you currently have any fever or infection?

YES________ NO__________

Explain:_____________________________________________________________

Are you currently taking any medication that affects your immunity?

YES___ NO___

Explain:_____________________________________________________________

Do you have any chronic heart problems, lung problems, cancer or disease affecting your immunity?

YES______ NO_______

Explain:_____________________________________________________________

Procedure:

After signing the consent below, you will be scheduled to receive the immunization in three doses (dose 1 - now, dose 2 - one month from now, dose 3 -six months from now). After the immunization series is completed, you will have a blood test for antibody to Hepatitis B virus. This blood test and the immunization injections are done without charge to you. If the blood test indicates you are not yet immune, additional doses may be given. If you will not be employed at this institution for the next 6 months, it is recommended that you complete the vaccine elsewhere.

Consent:

I have read the above statements about Hepatitis B virus vaccine and have had an opportunity to ask questions. I understand that in my work at University Hospitals I may be at increased risk of contracting Hepatitis B virus and that vaccination has been recommended to prevent my becoming infected or ill.

I consent to receive injections of Hepatitis B virus vaccine and to have blood drawn following the series.

NAME:___________________________________

EMPLOYEE ID#:___________________________

Signature:____________________________

Witness:_____________________________

Date:_____________________

Injection:

Lot:_______________ Dose:_____________ Site: ___________

Administered by:_____________________________

Hepatitis B Declination Statement:

I understand that due to my occupational exposure to blood or other potentially infectious materials 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. However, 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 blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

NAME:________________________________

EMPLOYEE ID#:_________________________________

Signature:________________________________

Witness:_________________________________

Date:___________________