- Hepatitis B vaccination is ____ is not ____ recommended for the
employee named above.
The employee named above is scheduled to receive the hepatitis B
vaccination on
the following dates:
- First of three ___________
- Second of three_________
- Third of three___________
Signature of health care provider:____________________________________
Printed or typed name of health care
provider:__________________________
This form is to be returned to the employer, and a copy provided to
the employee within 15 days.
Employer Name:______________________________
Title:_______________________________________
Address:_________________________________________________________