table of contents - UWA Athletic Training & Sports Medicine Center

The University of West AlabamaAthletic Training ProgramHepatitis B Vaccine Waiver FormAll athletic trainers, who have been identified as being at risk for exposure to blood or otherpotentially infectious materials, are offered the Hepatitis B vaccine. The three stage vaccine isoffered through The University of West Alabama's team physician, Dr. James Robinson or theMarengo County Health Department (Demopolis, AL) at minimal cost to the athletic trainingstudent. Dr. Robinson’s cost is $260 and Marengo County Health Department $5 to administer thevaccine and approximately $60 for the prescription at The Drug Store in Livingston. The SumterCounty Health Department will provide the vaccine and injection FREE if you are Nineteen Yearsof age or younger. The above stated costs are subject to change.I understand that due to my occupational exposure to blood or other potentially infectious materials, Imay be at risk of acquiring the Hepatitis B Virus (HBV). I wish to be vaccinated at this time at one of theabove locations. Upon which time I will submit my record of vaccination to the Program Director ofthe UWA Athletic Training Program.Student SignatureDateI have been given the opportunity to be vaccinated. However, I decline the vaccine at this time.I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, aserious disease. If in the future I continue to have occupational exposure to blood or otherpotentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I canreceive the vaccination series at the above expense through one of the above locations.Student SignatureDateStudent SignatureDateI have initiated my Hepatitis B vaccination and will be completing it within the next 6 months.Upon which time I will submit my record of vaccination to the Program Director of the UWAAthletic Training Program.Student SignatureDateCurrent Number of Injections TakenI have already received my complete Hepatitis B vaccination and will submit my record ofvaccination to the Program Director of the UWA Athletic Training Program.Student Signature51Date