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i <br /> San Joaquin County <br /> oPQUj`� cnvoron ent�1aOth Ott DIRECTOR <br /> Linda Turkatte,RENS <br /> y 1868 East Hazelton Avenue <br /> W: Stockton, Califarflia 96205®5232 PROGRAM COORDINATORS j <br /> Robert McClellon,REHS <br /> ® Jeff Carruesco,RENS,RDIKasey Foley,REHS <br /> ' <br /> r9t, oR�a�P Webolte.WWW.Sjgovot�g/ehc! Rodney Estrada,REHS <br /> Phone: (209)468-3420 Adrienne Ellsaesser,REHS <br /> Fax: (209)464.0138 <br /> RE <br /> JAN 9 fl , <br /> IONNIETAL HEALTH <br /> Hepatitis B Declination Statement* ITIEVICE <br /> The following statement of declination of hepatitis B vaccination must be signed by an <br /> employee who chooses not to accept the vaccine. The statement can only be signed by the <br /> employee following appropriate training regarding hepatitis B,hepatitis B vaccination,the <br /> efficacy,safety,method of administration,and benefits of vaccination,and that the°vaccine and <br /> vaccination are provided free of charge to the employee:The statement is not a waiver; <br /> employees can request and receive the hepatitis Bvaccination at a later date if they remain <br /> occupationally at risk for hepatitis B. 1 <br /> Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring hepatitis B virus(HBV)infection. I have been given the <br /> opportunity to be vaccinated with hepatitis B vaccine,at no charge to me;however,I decline <br /> hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be <br /> at risk of acquiring hepatitis B, a serious disease. If,in the future I continAe to have occupational <br /> exposure to blood or other potentially infectious materials and I want to be v4ccinated with <br /> hepatitis B vaccine,I can ' ive the vaccination series at no charge to me. <br /> Employee Signature: _Date: 1p?— <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities.OSHA Publication 3128, (1992). <br /> . 1 <br /> 1 <br /> • I <br /> I <br /> i <br />