Safety Training Record
June 2004
UMaine Athletic Training Education Program
Hepatitis B Vaccinations (HBV)

The University of Maine requires students entering into clinical education experiences in the Athletic Training Education Program (ATEP) to furnish evidence of HBV, or in the alternative, evidence that they hereby waive and decline HBV. Students acknowledge and understand that receiving the HBV is very highly recommended, but not required, for persons who have contact with blood and body secretions, such as healthcare workers and clinical students. The receipt of the HBV is voluntary.

Students acknowledge and understand that should they choose to have the HBV, and that it is their responsibility to pay for the service.

Students will be required to fill out an HBV Vaccination Verification Status Form prior to the start of their Clinical Education. In this form, they must agree or waive and decline the HBV prior to the start of their clinical experience.

HBV Vaccination Verification Status Form
Blood Borne Pathogen Awareness

I, _____________________________________, have participated in the educational program regarding the blood borne pathogen risks and disease transmission through the University of Maine.

I understand, and will practice Universal Precautions to reduce exposures to risk. Should I choose to assist in the first aid care of an injured physically active person, I understand that I may be at risk of exposure to blood borne pathogens. I accept that risk.

I am aware of the University of Maine’s exposure control plan as well as the process in the event of exposure.

I am aware that there is no known immunization or cure for Human Immunodeficiency Virus (HIV) nor Acquired Immune Deficiency Syndrome (AIDS).

I am also aware that an immunization is available to protect against the Hepatitis B Virus (HBV).

I choose to accept the immunization against HBV ___Yes ___No

If yes, I have provided proof of immunization ___Yes ___No

Print Name:_________________________________________________________

Signature of Name:____________________________________________________