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RFCEI'VED <br />OEC 0 4 Z91Z <br />Rv <br />,E A isil Ic Addendum L•• <br />0 <br />OSHA Hepatitis B Declination Statement <br />W <br />U11111111711 <br />BE EXACTLY AS WORDED BELOW. Copy is print, sign and turn In to your <br />e <br />m <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 />'Declination Statement: 1910.1030 App A <br />j <br />,,I understand that due to my occupational exposure to blood or other potentially infectious <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 it potentially infectious materials and I want to be vaccinated with <br />'hepatitis B vaccine, I can receive e vaccination series at no charge to me. <br />Employee Signature: <br />!Date: 11-ZBA-7= <br />Employer Signature: <br />