Hepatitis B Vaccination Declination
Name:
Address: ______________________
USC ID #: _____________________________
School:
Country: ______________ State: _ Zip: _____
Telephone Number: ____________
I, , decline Hepatitis B vaccination at this time.
I understand that by declining this vaccine, I continue to be at risk for acquiring Hepatitis B, a serious disease.
I have been given the opportunity to ask questions, and those questions have been answered and I understand the program.
I also understand that USC Student Health strongly urges and recommends I receive the vaccine.
I decline the Hepatitis B vaccination series.
I have already received the Hepatitis B vaccination series.
I have religious objections to being vaccinated.
I do not believe I have a risk of acquiring Hepatitis B.
I fear possible side effects of the vaccine.
Other:
Authorized By: