Hepatitis B Vaccination Request

Last Revised: April 24, 2019

Due to your occupational exposure to blood and other potentially infectious materials, you may be at risk of acquiring hepatitis B virus (HBV) infection. Hepatitis B vaccination is available to you at no charge from Occupational Medicine. To request a vaccine, fill out the form below. Additionally, request a letter of authorization from your Business Administrator which includes your name and outlines a list of authorized services. Send the letter to Tara Byrd at Tara.Byrd@uphs.upenn.edu to schedule an appointment. Once services have been rendered, Occupational Medicine will issue an invoice to your Business Administrator.

If you have any additional questions about the Hepatitis B Vaccination, please contact EHRS at 215-898-4453.

Do you wish to receive the Hepatitis B vaccination?

Yes

Accepting the Hepatitis B Vaccination

I will be receiving the Hepatitis B Vaccination Series. I will report to Occupational Medicine, Hospital of the University of Pennsylvania(HUP) Ravdin Building 2nd floor, 34th and Spruce Street.

Hours for immunizations are 7:30 am to 5 pm. You will not be charged.

Vaccinations must be paid for by your department. An authorization letter for Hepatitis B vaccination signed by your department's business administrator is required by Occupational Medicine.

Declining the Hepatitis B Vaccination

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 vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.

In the future if 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.

I have received or decline the vaccine

I have already received the Hepatitis B Vaccination series

I decline to take the Hepatitis B Vaccination series

In what year did you receive your vaccine?

First Name

Last Name

Email Address

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.