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The following statement of declination of the hepatitis B vaccine must be signed by an employee who: • Chooses not to accept the vaccine. • Has had appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration and benefits of vaccination, given free of charge to the employee. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially i fectious materials and I want to be vaccinated with hepatitis B vfccine, T/ c n r ceive frliie vaccination series at no charge to me. / � ate: ZL-4� • This statement 1s not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B. San Joaquin t Environmental I DIRECTOR 1868 East Hazelton Avenue Donna Heran, RENS Stockton, California 95205-6232 PROGRAM COORDINATORS Robert McClellon, RENS Jeff Carruesco, REHS, RDI Website: www.sjgov.org1ehd Kasey Foley, REHS Phone: 209 468-3420 ( ) Linda Turkatte, REHS Rodney Estrada, REHS Fax: (209) 464-0138 Adrienne Ellsaesser, REHS The following statement of declination of the hepatitis B vaccine must be signed by an employee who: • Chooses not to accept the vaccine. • Has had appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration and benefits of vaccination, given free of charge to the employee. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially i fectious materials and I want to be vaccinated with hepatitis B vfccine, T/ c n r ceive frliie vaccination series at no charge to me. / � ate: ZL-4� • This statement 1s not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B.