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Hepatitis 8 Vaccine Declination Form <br /> The following statement of declination of the hepatitis B vaccine must be signed by <br /> an employee who: <br /> • Chooses not to accept the vaccine. <br /> 0 <br /> Flash appropriate training regarding hepatitis B, hepatitis 8 vaccination, <br /> the efficacy, safety, method of administration and benefits of vaccination, <br /> given free of charge to the employee. <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials I may be at risk of acquiring hepatitis 8 virus (HBV) infection. I <br /> have been given the opportunity to be vaccinated with hepatitis 8 vaccine, at no <br /> charge to myself. However, I decline hepatitis B vaccination at this time. I <br /> understand that by declining this vaccine I continue to be at risk of acquiring <br /> hepatitis 8, 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 <br /> vaccinated with hepatitis B vaccine, I can receive the v natio series at no charge <br /> to me. <br /> Employee Signature: ate* <br /> This statement Is not a waiver; employees car► request and receive the <br /> hepatitis B vaccination at a later date If they remain occupationally at risk for <br /> hepatitis B. <br /> An employer can not require: <br /> • Employees to waive liability in order to receive the vaccine <br /> • Participation In pre-screening as a prerequisite for receiving the vaccine. <br />