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RADFORD UNIVERSITY

HEPATITIS-B VACCINE

I, ______________________________________________, request that the Hepatitis-B Vaccine be administered to me by the appropriate health care provider. I have consented to the administration of this vaccine due to the possibility of occupational exposure to bloodborne pathogens. I have received training concerning the OSHA standard for exposure to bloodborne pathogens and understand the benefits and risks of the vaccine.

SIGNATURE_________________________________

DATE______________________________________

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FIRST INJECTION

Date:____________________________ Site: Rt Deltoid    Lt Deltoid

Administered By:_________________ Dosage: ___________________ (IM)

Manufacturer:____________________ Lot# ______________________

 

SECOND INJECTION (one month later)

Date:___________________________ Site: Rt Deltoid    Lt Deltoid

Administered By:________________ Dosage: ___________________ (IM)

Manufacturer:___________________ Lot# ______________________

 

THIRD INJECTION (6 months after initial injection)

Date:___________________________ Site: Rt Deltoid    Lt Deltoid

Administered By:________________ Dosage: ___________________ (IM)

Manufacturer:___________________ Lot# ______________________