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` • <br /> .Stir/!/ � <br /> DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 Cornucopia Way,Suite C,Modesto,CA 95358-9492 <br /> Phone:209.525.6700 Fax:209.525.6774 <br /> www.stancounty.com <br /> i1y <br /> RIrls,"(1 IO OA/A@ DOS) <br /> Hepatitis B Vaccination Declination Form <br /> in accordance with OSHA requirements eMplovers must make hepatitis B vaccinations available at no 1 <br /> cost to employees who have an occupational exposure to the hepatitis B virus (HBV) Body art <br /> Practitioners are required to submit evidence of current hepatitis B immunity in conjunction with <br /> registration materials. This includes records of hepatitis B vaccinations and booster shots. If a <br /> Practitioner declines to be vaccinated against HBV he she must submit a signed declination <br /> agreement from his/her employer. A sample declination statement is provided below. Contact <br /> Occupational Safety&Health Administration(www osha gov)for additional information <br /> Waiver of Hepatitis B Vaccine <br /> understand that due to my occupational exposure to blood <br /> Other Potentially Infectious Materials(OPIM),I may be at risk of acquiring hepatitis B virus(HBV) <br /> infection.I have been given the opportunity to be vaccinated with hepatitis B vaccine,at no charge to <br /> myself.However,I decline hepatitis B vaccination at this time.I understand that by declining this <br /> vaccine,I continue to be at risk of acquiring hepatitis B,a serious disease.If in the future I <br /> continue to have occupational exposure to blood or or OPIM and I want to be vaccinated with hepatitis <br /> B vaccine,I can receive the vaccination series at no charge to me." <br /> [S6 FR 64004,Dec.06,1991,as amended at 57 FR 12717,April 13,1992;57 FR 29206,July 1,1992;61 <br /> FR 5507,Feb.13,19961 <br /> Date Employee's Printed Name Employee's Signature <br /> o �- 0o6A�� <br /> Date Employer Representative's Printed Name Employer Representative's Signature <br />