Hepatitis B Vaccination Waiver Form
Use this form to request a waiver related to Hepatitis B vaccination and provide the information needed for review. Do not include sensitive medical details.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Vaccination Waiver Details
Reason for Requesting Waiver
*
Please Select
Medical concern
Personal belief
Religious belief
Prior vaccine reaction
Deferred by healthcare provider
Other
Do you have any vaccination-related concerns or prior reactions?
*
Yes
No
Brief Explanation
*
Waiver Acknowledgment
Applicant Signature
*
Submission Confirmation
Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes for Reviewer
Submit Waiver Request
Submit Waiver Request
Should be Empty: