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Hepatitis B Declination Statement <br />The following statement of declination of hepatitis B vaccination must be signed by an <br />employee who chooses not to accept the vaccine. The statement can only be signed by <br />the employee following appropriate training regarding hepatitis B, hepatitis B <br />vaccination, the efficacy, safety, method of administration, and benefits of vaccination, <br />and that the vaccine and vaccination are provided free of charge to the employee. The <br />statement is not a waiver; employees can request and receive the hepatitis B vaccination <br />at a later date if they remain occupationally at risk for hepatitis B. <br />Declination Statement <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 me; however, I decline hepatitis B vaccination at this time. I understand <br />that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a <br />serious disease. If, in the future I continue to have occupational exposure to blood <br />or other potentially infectious materials and I want to be vaccinated with hepatitis B <br />vaccine, I can receive the vaccination series at no charge to me. <br />7 <br />Employee Name (print) <br />Employee Signature: <br />