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0 <br /> San Joaquin county <br /> DIRECTOR <br /> v. 1ronmental Health Department <br /> En Linda Turkatte,REHS <br /> 1% 1868 East Hazelton Avenue <br /> Q. -A <br /> PROGRAM COORDINATORS <br /> t <br /> Sackton, Calffornia 95205-6232 <br /> X <br /> Robert McClellon,REHS <br /> • Jeff Carruesco, REHS,RDI <br /> cq Web-site: tvvifurSjigcv.orglehd Kasey Foley, REHS <br /> �j F6..z Rodney Estrada,REHS <br /> Phone: (20SI) 463-3420 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: Date: /� <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />