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Sean' Jc-j'a q u 1,11 DIRECTOR Linda Turkatte,REHS z. 1868 East Hazeftan Avenue ncktcn, Caflforir0a 9,520506232 PROGRAM COORDINATORS Robert McClellon, REHS jeff Carruesco, REHS,RD! .4L Kasey Foley, REHS 0 Rodney Estrada, REHS Phot-Le: (209�4e3-34-20 Adrienne Ellsaesser, REHS Fax: (20,091) 464-0138 Hepatitis B Declination Statement* The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate regarding arding hepatitis B, hepatitis B vaccination, the - 9 efficacy, safety, method of administration, and benefits of vaccination, mad that the vaccine and vaccination are provided free of charge to the employee. The statement is not a Waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B. Declination Statement I understand that due to--my occupational exposure to blood or other-potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opporr�rtunity to be vaccinated 17,71ith hepatitis B vaccine, at n -n o charge to - e- 'In-17a s - .TPvPr T rb-r�linF-. hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Signature: Date: *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992).