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Hepatitis B Virus Vaccination Authorization


About this Form

Form number: 230-32

Audience:  MCPS Staff

Last revised: July 2023

INSTRUCTIONS:  MCPS staff must complete Section I of this form and send to the Systemwide Safety Programs office BEFORE taking the form to tru HealthNow (formerly Medical Access). ​The form can be faxed to 301-279-3192, scanned and sent by email to, or sent via Pony to the address above. Preventive vaccinations are offered free of charge for all MCPS staff* who are required to take annual bloodborne pathogens exposure prevention training (*listed in the MCPS Bloodborne Pathogens Exposure Control Plan found on the MCPS Bloodborne Pathogen Information webpage), and/or MCPS staff who experience a bloodborne pathogen exposure incident. Employees should take this completed form to the health care center listed below to receive the preventive vaccination. MCPS staff who decline the vaccination, are required to submit MCPS Form 230-31, Mandatory Hepatitis B Virus Vaccination Declination Statement annually. Questions regarding the MCPS Bloodborne Pathogens program may be directed to Systemwide Safety Programs at 240-740-7710.

Note: All medical records shall be kept confidential and may not be disclosed or reported without the employee's express written consent to any person within or without the workplace except as required by law, but may be reviewed and copied by the employee who is the subject of the file.

Adobe PDF Hepatitis B Virus Vaccination Authorization
78 KEnglish
Adobe PDF Autorización de Vacunación contra el Virus de Hepatitis B CONFIDENCIAL56 KSpanish

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