Adopted: 08/18/1988

Revised:  02/18/2008

                                                                                                  523.4 Exhibit 2

School District of Prairie Farm

Information and Procedures in Dealing with Exposure

HEPATITIS B VACCINE DECLINATION

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 vaccination at this time.  I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.  If in the future 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 to me.

Employee Name (please print): ____________________________________________________

Employee Signature: ____________________________________________________________

Date: ______________________