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San JoaquJin klpouinttT <br /> De- <br /> O.P10 U"I Healith, pa,o t na,9 ni DIRECTOR <br /> Linda Turkatte,REHS <br /> 8 East H,a a e o n A, venue <br /> PROGRAM COORDINATORS <br /> U): < <br /> St <br /> Robert McClellon,REHS <br /> Jeff Carruesco, REHS,RD! <br /> Kasey Foley, REHS <br /> C- Rodney Estrada,REHS <br /> Z'j <br /> Phone: (209) 4,63-334-20 Adrienne Ellsaesser, REHS <br /> Fax: (20031) 4,64-0133 <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 acquiring hepatitis B virus (HBV) infection. I have been Oven the <br /> opl-, wever, I declineit-, to be vaccinated with hepatitis B vaccine, at no charge to me; ho <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 infectiou5,j nd I want to be vaccinated with <br /> hepatitis B vaccine, I can rec the vaccinat"i-on series at n charge to me. <br /> o <br /> Employee Signt�ue;,-'-'/' ate: <br /> r <br /> 0rne 7Pat <br /> *Taken from: 61 hoge sand d cute Care Facilities. OSHA Publication 3128, (1992). <br /> �OO b, <br />