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DEPARTMENT OF ENVIRONMENTAL. RESOURCES <br /> 3800 Cornucopia Way,Suite C,Modesto,CA 95358-9492 <br /> Phone:209.525.6700 Fax:209.525.6774 <br /> www.stancounty.com <br /> i;wy <br /> Hepatitis B Vaccination Declination Form <br /> In accordance with OSHA,reauiFements employers must make hepatitis B vaccinations available at no <br /> ccQ9 to employees who,tavq an occupational exposure to the hepatitis B vim W130. §ody art <br /> practitioners are required to submit evidence of current hepaticas B !mmumity in SopjLMWon with <br /> MgisjLagon Materials. This includes ecords of he tins B IMccinations andf <br /> practitioner declines to be vaccinated against HBV he/she must submit a signed deSlinatl2n <br /> agreement from his/hSr gmploy rq_A sample declination stateMat Is providtd elow„.Contact <br /> Occupational Safety&Health Admin ration r gsha govj,for additional information <br /> 11 Wer of Hepatitis B Vaccine <br /> understand that due to my occupational exposure to blood <br /> Other Potentially Infe ious Materials(OPIM),I may be at risk of acquiring hepatitis B virus(HBV) <br /> Infection.I have been given the opportunity to be vaccinated with hepatitis B vaccine,at no charge to <br /> myself.However,I decline hepatitis B vaccination at this time.I understand that by declining this <br /> vaccine,l continue to be at risk of acquiring hepatitis B,a serious disease. If in the future I <br /> continue to have occupational exposure to blood or or OPIM and I want to be vaccinated with hepatitis <br /> B vaccine,i can receive the vaccination series at no charge to me." <br /> [56 FR 64004,Dec.06,1991,as amended at 57 FR 12717,April 13,1992;57 FR u y 1992;61 <br /> FR 5507,Feb.13,1996] <br /> Affxl it, <br /> Z/ <br /> f� .. <br /> Date Employee's Printed N Employee's Signature <br /> Date E 'oyer epres tative's Printed Name Employer Representative's Signature <br />