Appendix 2

Hepatitis B Vaccination Consent Form

I consent to receive hepatitis B vaccination. It is my understanding that this vaccine has been found to be safe and effective in preventing hepatitis B virus infection. The course of vaccination requires three injections over a six month period (i.e., 0, 1, and 6 months). It is my understanding that, to date, there have been no reported incidents of serious adverse reactions as a result of these injections. Minor side effects may include such symptoms as soreness, swelling at the site of the injection, low grade fever (less than 101oF), fatigue, headache, and nausea in the week following the injection.

I have had an opportunity to ask and receive answers to all of my questions. I have been informed that women receiving this vaccine are advised to avoid becoming pregnant for three months after each vaccination.

I agree to release Rutgers University from all responsibility, should I have complications of hepatitis B vaccination.

Printed Name:_______________________________________________

Social Security Number:
______________________________________

Department:
________________________________________________

Job Title:
___________________________________________________

Signature:
__________________________________________________

Witness:
____________________________________________________

Date:
_______________________________________________________

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