Adopted: 08/18/1988

Revised:  02/18/2008

                                                                                                  523.4 Exhibit 4

School District of Prairie Farm

HEPATITIS B VACCINATION RECORD

I understand 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 information on the hepatitis b vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.

I, __________________________ have completed the following inoculations using:

______Recombivax-HB Vaccine         or         ________        Enerix-B Vaccine

-- Inoculation 1 Date: ________                                   Given at: ________________

-- Inoculation 2 Date: ________                                   Given at: ________________

-- Inoculation 3 Date: ________                                   Given at: ________________