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Hepatitis B Declination Statement* DIRECTOR Linda Turkatte, REHS PROGRAM COORDINATORS Robert McClellon, REHS Jeff Carruesco, REHS, RDI Kasey Foley, REHS Rodney Estrada, REHS Adrienne Ellsaesser, REHS The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is 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. Declination Statement 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 me; 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 infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Signature: .&�') Date *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). San Joaquin County • Environmental Health pII :..: East HazeltonAvenue Stockton,95205-6232 Website: www.sjgov.org1ehd 0• 468-3420 t•464-0138 Hepatitis B Declination Statement* DIRECTOR Linda Turkatte, REHS PROGRAM COORDINATORS Robert McClellon, REHS Jeff Carruesco, REHS, RDI Kasey Foley, REHS Rodney Estrada, REHS Adrienne Ellsaesser, REHS The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is 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. Declination Statement 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 me; 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 infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Signature: .&�') Date *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992).