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San Joaquin County <br />PpUtN C Environmental Health Department <br />1868 East Hazelton Avenue <br />X Stockton, California 95205-6232 <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 464-0138 <br />Hepatitis B Declination Statement* <br />DIRECTOR <br />Linda Turkatte, REHS <br />PROGRAM COORDINATORS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />Rodney Estrada, REHS <br />Adrienne Ellsaesser, REHS <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 B vaccination at a later date if they remain <br />occupationally at risk for hepatitis B. <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 continue to have occupational <br />exposure to blood or other potentially infectious materials and I want to be vaccinated with <br />hepatitis B vaccine, I can receive the vaccination series at no charge to me. <br />Employee Signature: Date: .,?- / l <br />*Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />