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DIRECTOR <br /> = � GGt �� Lr Linda i urkatte,REHS <br /> 1868' East � az � <br /> r pa r PROGRAM COORDINATORS <br /> X S'e�'c��LC'bti, C�auCfo`6`n a 9,52,05--3 '32 <br /> T :c Robert McClellon,REHS <br /> Jeff Carruesco, REHS RD! <br /> a Kase Foley, REHS <br /> Y Y <br /> Rodney Estrada, REHS <br /> Plici-ics: (202') 4'68=34=20 Adrienne Ellsaesser, REHS <br /> Fax: (209)) 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 /> Cnrrn t inity to be,vac.emate.d with hepatitis R vir.rinP.o at no c.liar:ra to m—e° liovrev r I d-1— <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 11 CtiviiS materials and I want to be vaccinated with <br /> hepatitis B vaccine, I can receiv cina 'on series at no charge to me. <br /> Employee Signature- Date: 6f 4Z 27 /1 <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />