NORTHWEST HEALTH SERVICES, INC.

HEPATITIS B VACCINATIONS RELEASE FORM

The FDA licenses vaccines providing protection against the Hepatitis B virus. Clinical studies indicate that administration of the vaccine, in three (3) doses over several months, may produce immunity in 82-90% of recipients.

The Center for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) have issued statements recommending vaccinations be offered to health care workers who perform procedures that involve:

·  Inherent at-risk potential for mucous membrane; or

·  Direct skin contact with blood, body fluids or tissues; or

·  Potential for direct contact through spills or splashes of blood or body fluids that have been recognized by CDC as directly linked to the transmission of HIV and/or HBV, and/or

·  Risks to which universal precautions apply including, but not limited to, blood and other body fluids containing visible blood, semen, blood products, vaginal secretions, cerebrospinal fluid, snynovial fluid, pericardial fluid, and amniotic fluid.

Staffs that may be in the substantial risk category include those in direct nursing care.

Studies involving use of the vaccine in pregnant and nursing women have not been performed, and the opportunity to receive the vaccine will be given in these situations only if clearly needed and at the written recommendation of your personal physician.

The vaccine is offered on a completely voluntary basis. Your decision to receive or not receive the vaccine is purely a personal decision. If you have further questions or concerns about the vaccine, please contact your personal physician before requesting the vaccination.

RELEASE

I understand that I have been given the option by NHS of receiving the Hepatitis B vaccine series at agency expense and without charge to me. I fully realize that administration of the vaccine may possibly result in complications including, but not limited to: injection site reactions consisting of soreness, pain, tenderness, pruritus, erythema, ecchymosis, swelling, warmth, and nodule formation. Other adverse reactions may include feeling fatigue/weakness, sweating, achiness, sensation of warmth, light-headedness, chills, flushing, vomiting, abdominal pains/cramps, dyspepsia, diminished appetite, rhinitis (runny nose), influenza, cough, vertigo/dizziness, paresthesia, non-specified rash, angioedema, urticaria, arthralgia, myalgia, back, neck and shoulder pain, lymphadenopathy, insomnia/disturbed sleep, earache, dysuria, and hypotension.

Other complications that have been reported included hypersensitivity with a wide variety of symptoms, including fever, dermatological reactions, nose bleeds, chest discomfort, heart palpitations, bronchial spasms and serum sickness-like symptoms with a delayed onset of days to weeks after vaccination. Other reactions reported include Bell’s palsy, muscle weakness and optical neuritis.

(HEP B continued)

I also understand that any time a medication is given by injection unknown and potential serious allergic complications may occur.

I fully understand the risks of receiving these injections and hereby release and forever release NORTHWEST HEALTH SERVICES, its officers and directors, its medical and nursing staff, agents, employees, and any other persons connected with the administration of the vaccine from any and all liabilities, claims, damages, and causes of actions that may arise from the administration of the vaccine series and/or its possible complications. This release is to be binding upon my spouse, as well as my heirs, legal representatives and assigns.

I have fully read all of the terms of this release and understand that this is a complete release and bars any and all claims resulting in the administration of the vaccine series and any possible complications regardless of whether specifically described herein.

After reading the above information about the Hepatitis B vaccine, please read and sign the following release indicating your decision regarding the vaccine.

______I do NOT wish to receive the vaccine.

______I have already been given the vaccine on______.

(date)

______I request that the vaccine be administered and consent to the administration of the

vaccine.

I hereby certify that I, ______,

(Please Print Name)

as an employee at NORTHWEST HEALTH SERVICES, INC., have fully and completely read and understand the above information regarding the administration of the Hepatitis B vaccine series and by my choice, and at my risk and responsibility, hereby release, hold harmless, and agree to indemnify responsibility or consequences which may result from my decision to receive or not receive the Hepatitis B vaccine.

______

Signature Date

______

Witness Date

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