_KCTCS

_{Jefferson Community College}

_{DECLINATION FORM}

_{Hepatitis B Vaccination}

_{I understand that as a student enrolled in the Jefferson Community College Radiography Program, I may be exposed to infectious diseases or blood-borne pathogens such as the Hepatitis B Virus. I further understand that as a result of this exposure, I may acquire the Hepatitis B Virus or another infectious disease.}

_{The Radiography Faculty and Jefferson Community College strongly recommend that I receive the Hepatitis B Vaccination.}

_{Even though I have been informed of the potential risk, I decline to receive the vaccination at this time.}

_{I realize that by declining to have the Vaccination, my clinical experiences may be limited/refused. Jefferson Community College does not accept any responsibility for this, because the immunization policy is a requirement of the affiliating clinical agencies and not that of the University.}

_{I further realize that without the immunization, I remain at risk for acquiring the disease for which the immunization is indicated. Jefferson Community College Radiography Program will not assume any cost or charges if I decide to receive the immunization now or in the future.}

_{Date: __________________ Name: _______________________________}