* Required Information
CONFIDENTIALITY OF CLIENT INFORMATION
Agency personnel must read and sign their acknowledgment of the following statement: By accepting employment with Agency, I agree to carefully refrain from discussing any clients condition or personal affairs with anyone outside the agency: unless expressly authorized to do so. I will not share any medical information with other clients or visitors without clear instruction provided to the agency. I acknowledge that All information seen or heard regarding clients. dilectly or indirectly: is completely confidential and is not to be discussed, even with my family or coworkers. My job as an employee requires that I govern myself by high ethical standards. Failure to recognize the importance of confidentiality is not only a breech of professional ethics, but can also involve an employee in legal proceedings. I will not share any Infomation about clients or the agency with the media. This is essential for protection of both the client and Agency.

I have read and understood the above statement and agree to abide by these policies.

I understand that a breach of policy may result in disciplinary action and possible dismissal from employment.

EMPLOYEE MEDICAL INFORMATION CHECKLIST

Please choose all conditions which you have now or have had

HEPATITIS B VACCINATION CONSENT/WAIVER FORM

A. Consent for Hepatitis B Vaccine

I , consent to be immunized against Hepatitis B.

I acknowledge the following:

  1. I have been informed that am at risk of acquiring hepatitis B because of the nature of my professional responsibilities.
  2. I have read the information sheet that lists the indications, benefits, and presently known side effects of hepatitis B vaccine: have had an opportunity to ask questions, and have had them answered to my satisfaciion.
  3. I must receive three (3) doses of vaccine over a period of six (6) months to confer optimal immunity
  4. I understand, however, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse reaction to the vaccine.
  5. In the event that I experience any adverse side effects or do not become immune from the vaccine I hereby hold Neighbors Keeper Home Health. harmless from any and all liabiiity to the extent permitted under the law.
  6. In the event that I should terminate employment at Neighbors Keeper Home Health. prior to receiving all three (3) doses of hepatitis B vaccine, I understand that it will be my responsibility to complete the vaccination series on my own initiative and at my own expense.



B. Previous Immunization with Hepatitis B Vaccine

I , have previously completed a three-dose series of the Hepatitis B at in


C. Refusal to Receive Hepatitis B Vaccine

I , understand that due to my occupational: exposure to blood or other potentially infectious materials 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, decline hepatitis B vaccination at this time. I understand that by declining this vaccine 1 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.