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San Joaquin county <br /> DIRECTOR <br /> ErMronmenta�i Heafth Depaeu-nent <br /> Linda Turkatte,REHS <br /> 1868 East Hazelton Avenue <br /> PROGRAM COORDINATORS <br /> x Stockton, Caffornia 95205-6232 <br /> Robert McClellon, REHS <br /> Jeff Carruesco, REHS,RDI <br /> � Webssfte: tYv,1i1Ksjgcv.org1ehd Kasey Foley, REHS <br /> Rodney Estrada,REHS <br /> Phone: (209) 463-3420 Adrienne Ellsaesser,REHS <br /> Fax: (209) 464-0138 <br /> 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 the <br /> employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the <br /> efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and <br /> vaccination are provided free of charge to the employee. The statement is not a waiver; <br /> employees can request and receive the hepatitis B vaccination at a later date if they remain <br /> occupationally at risk for hepatitis B. <br /> Declination Statement <br /> I understand that due to my occupational'exposure to blood or other potentially infectious <br /> materials I may be at risk of acquirin h:6pitis B virus (HBV) infection. I have been given the <br /> opportunity to be vaccinated with hyepatiti,, t, Vvaccine, no cha <br /> I ie to me; however, I decline <br /> hepatitis B vaccination at this tire. staild the decl_ ing this vaccine I continue to be <br /> e. I <br /> at risk of acquiring hepatitiXB,,.-,a serio e e. in the tore I continue to have occupational <br /> exposure to blood or 0th otential fec us aterials and I want to be vaccinated with <br /> hepatitis B vaccine, I c re-ie i v e h vacs' ti series no charge to me. <br /> Employee Signator z. <br /> Date: <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />