Form

Paoli Community School Corporation

Health and Prevention in the School Setting Training

This training is intended for all employees, contractors and partners working in the school setting and the signed, submitted completion of this training will be kept on file by the corporation's Licensed School Nurse and Superintendent

Full Name *

First Name Last Name

Today's Date *

- Month - Day Year

Building/Position *

Step 1: Read both the Hepatitis B Vaccine and the Blood and Infectious Materials Exposure Control Plan information below and then proceed to the next step.

Step 2: To RECEIVE or DECLINE the Hepatitis B vaccination series, select one option below.

Vaccination Plan (Select your plan) *

I choose to RECEIVE the series of Hepatitis B Virus vaccines and understand I may contact the Orange County Health Department (205 E. Main St., Paoli, IN; (812)723-7112) to make an appointment and receive shots (Costs paid by the corporation only for those noted in the Exposure Control Plan). I have read the Hepatitis B Virus (HBV) vaccination information sheet. I understand my occupation may lead to exposure to blood or other potentially infectious materials and I may be at risk of acquiring HBV. I have the opportunity to be vaccinated with the vaccine but I decline at this time. I understand that by declining this vaccine I continue to be at risk of acquiring HBV, a serious disease. If I continue to have occupational exposure to blood or other potentially infectious materials I may elect to be be vaccinated with the vaccine (Costs paid by the corporation only for those noted in the Exposure Control Plan).

Step 3: Read the Guidelines for the Prevention of Bloodborne Infectious Diseases During Student Activities information and then acknowledge your understanding below.

I have read and understand the Hepatitis B Vaccine information, Blood and Infectious Materials Exposure Control Plan, Guidelines for the Prevention of Bloodborne Infectious Diseases During Student Activities information, and also understand I am to contact the School Nurse with any questions that may arise. *

Yes, I understand

Step 4: Read the Universal Precautions information below.

I have read and understand the Universal Precautions information and I also understand I am to contact the School Nurse with any questions that may arise. *

Yes, I understand

As an employee, contractor or partner of Paoli Community School Corporation, I understand I shall follow the guidelines included in this training to promote and protect the health and safety of myself and others. I also understand I may access all the information contained in this training on the school corporation website for future reference and if any questions arise I shall contact the corporation's School Nurse. *

Yes, all the above is understood and my signature below indicates my completion of this training

Signature *

Clear