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San n"a'gejill Count 5o�c•�'`'•..cC? ��E�R��i�C��:�_C E��E�E�Ij �E��a�rv'�� 6 1860' Easy: H-azeKon avenue :< CLockton, Gar foriMa 95205-6232 'VY c�<�` �r €ifebsh''C: t��Erntr:�f�' r .ct`cr/GES P6?- PG' oiler (209) 4-68-3420 Fax: (209) 464-0138 Hepatitis B Declination Statement* DIRECTOR Linda Turkatte, REHS PROGRAM COORDINATORS Robert McClellon, REHS ,Jeff Carruesco, REHS, RD! 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 oppoitanity 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).