Laserfiche WebLink
onr 'al hl,,c �,Ih DIRECTOR <br /> Enmln uyttant a,Ii t �I D"e p"a,b C En. <br /> Linda Turkatte, REHS <br /> 269 East Hazelban Avenue <br /> N PROGRAM COORDINATORS <br /> W: X <br /> S-tockdccn, C-al"Norrtla 9,52,05-62,32, Robert McClellon,REHS <br /> jeff Carruesco, REHS, RD! <br /> Kasey Foley,REHS <br /> Rodney Estrada, REHS <br /> Adrienne Ellsaesser, REHS <br /> Fax: (20021) 464-0133 <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 /> i <br /> nni-trinity to be vaccinated v,7ith hepatitic charge to ?r e; hov,ever, I derlin?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 /> IT <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: VQ �ZDate: (0 2—--5 <br /> U <br /> "Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />