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San Joaquin County <br /> DIRECTOR <br /> Environmental Health Department <br /> Linda Turkatte, REHS <br /> 1868 East Hazelton Avenue <br /> 4. <br /> PROGRAM COORDINATORS <br /> Stockton, California 95205-6232 Robert McClellon,REHS <br /> Jeff Carruesco,REHS,RD] <br /> 0 Website: www.sjgov.org1ehd Kasey Foley, REHS <br /> F:0 Rodney Estrada,REHS <br /> Phone: (209)468-3420 Adrienne Ellsaesser, REHS <br /> Fax: (209)464-0138 <br /> Hepatitis B Declination Statement* <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: ftkU0C)M&:- Date: (o12-1 (-7 <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />