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Hepatitis B 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 />• Has had appropriate training regarding hepatitis B, hepatitis B 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 B virus (HBV) infection. I <br />have been given the opportunity to be vaccinated with hepatitis B 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 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 <br />vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge <br />to me. <br />Employee Signature: Date: <br />• This statement is not a waiver; employees can 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 />