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FFG 4212 <br />' <br />H <br />EALTH <br />Ft4\jjjFk0,11j11E0""L0ES <br />�M TISF-Mil <br />Addendum L. <br />OSHA Hepatitis B Declination Statement <br />'41907ff <br />BE EXACTLY AS WORDED BELOW. Copy the form, print, sign and turn In to your <br />employee. Found at: <br />The following statement of declination of hepatitis B vaccination must be signed by an employee <br />who chooses not to accept the vaccine. The statement can only be signed by the employee <br />following appropriate training regarding hepatitis b, hepatitis b vaccination, the efficacy, safety, <br />method of administration, and benefits of vaccination, and that the vaccine and vaccination are <br />provided free of charge to the employee. The statement is not a waiver; employees can request <br />and receive the hepatitis b vaccination at a later date if they remain occupationally at risk for <br />hepatitis b. <br />MEUMUZ=� <br />11 understand that due to my occupational exposure to blood or other potentially infectious <br />I <br />materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the <br />opportunity to be vaccinated with hepatitis b vaccine, at no charge to me; however, I decline <br />hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be <br />at risk of acquiring 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 vaccinated with <br />Msmz��� <br />Nw, 'A <br />�Employer Signatut <br />Date: <br />MF-= <br />