Form FDACS-01392 "Hepatitis B Vaccination Notice & Record" - Florida

What Is Form FDACS-01392?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form FDACS-01392 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-01392 "Hepatitis B Vaccination Notice & Record" - Florida

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Florida Department of Agriculture and Consumer Services
Office of Agricultural Law Enforcement
HEPATITIS B VACCINATION NOTICE & RECORD
ADAM H. PUTNAM
COMMISSIONER
I have received Bloodborne Pathogen Training and understand that due to my possible occupational
exposure to blood or other potential 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 series at
no cost to me. I understand that should I decline the vaccination I will continue to be at risk of acquiring
Hepatitis B, a serious disease. If, in the future, I change my mind or have an occupational
exposure to blood or other potentially infectious materials and want to receive the pre/post exposure
Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.
Please fill out the following:
Employee’s Name:
Employee’s Signature:
Date Form Signed:
Employee I.D.:
Hire Date:
Please select one of the options below:
I have elected to receive the Hepatitis B vaccination series. I understand that it is my
responsibility to return the completed Hepatitis B Vaccination Notice and Record form to
the Exposure Control Officer upon conclusion of the vaccination series.
I hereby decline the Hepatitis B Vaccination Series.
It is important that you receive the shots in a timely manner, as prescribed by the attending medical
personnel or physician.
INJECTION
DATE
ADMINISTERED BY
st
Hepatitis B - 1
Shot:
nd
Hepatitis B – 2
Shot:
st
(30 Days from 1
Shot)
rd
Hepatitis B – 3
Shot:
nd
(Five Months from 2
Shot)
Post-Vaccination Titer:
rd
(1-6 Months after 3
Shot)
Original - To be maintained by employee and signed by licensed healthcare professional upon receipt of injections.
FDACS-01392 06/16
Florida Department of Agriculture and Consumer Services
Office of Agricultural Law Enforcement
HEPATITIS B VACCINATION NOTICE & RECORD
ADAM H. PUTNAM
COMMISSIONER
I have received Bloodborne Pathogen Training and understand that due to my possible occupational
exposure to blood or other potential 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 series at
no cost to me. I understand that should I decline the vaccination I will continue to be at risk of acquiring
Hepatitis B, a serious disease. If, in the future, I change my mind or have an occupational
exposure to blood or other potentially infectious materials and want to receive the pre/post exposure
Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.
Please fill out the following:
Employee’s Name:
Employee’s Signature:
Date Form Signed:
Employee I.D.:
Hire Date:
Please select one of the options below:
I have elected to receive the Hepatitis B vaccination series. I understand that it is my
responsibility to return the completed Hepatitis B Vaccination Notice and Record form to
the Exposure Control Officer upon conclusion of the vaccination series.
I hereby decline the Hepatitis B Vaccination Series.
It is important that you receive the shots in a timely manner, as prescribed by the attending medical
personnel or physician.
INJECTION
DATE
ADMINISTERED BY
st
Hepatitis B - 1
Shot:
nd
Hepatitis B – 2
Shot:
st
(30 Days from 1
Shot)
rd
Hepatitis B – 3
Shot:
nd
(Five Months from 2
Shot)
Post-Vaccination Titer:
rd
(1-6 Months after 3
Shot)
Original - To be maintained by employee and signed by licensed healthcare professional upon receipt of injections.
FDACS-01392 06/16