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WX <br />DEPARTMENT OF ENVIRONMENTAL. RESOURCES <br />3800 Cornucopia Way, Suite C, Modesto, CA 95358-9492 <br />Phone: 209.525.6700 Fax: 209.525.6774 <br />Hepatitis B Vaccination Declination Form <br />www.stancounty.com <br />In accordance millh OSHA requirements, <br />emploversmust <br />make hepatlt s B i -0-%1I ations <br />available at no <br />cost to employees who have <br />an occupational <br />exposure <br />to the hepatitis B virus <br />(HBV). Body ark <br />12=11120ers are Lqgulred to <br />submit evidence <br />of current <br />hepatifxs B lmmunity in <br />conlunction with <br />registration materiais. This <br />lnclUles records <br />of hepatitis <br />B vaccinations and booster <br />shpts. If a <br />practitioner declioSs to be <br />vacdnated <br />against HBV, he/she <br />must submit a <br />signed declination <br />agreement from employer. <br />A <br />sample declination <br />sta ement is orovlded <br />below. Contact <br />,hijbgr <br />Occupational Safety & Health <br />Ali ministration <br />(www.osha. <br />ov,for additional information. <br />Waiver of Hepatitis B Vaccine <br />/e' ` erstand that due to my occunational exnosure to blood <br />Other Potentially Infectious Materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) <br />infection. l 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. l 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 29206, July 1,1992; 61 <br />FR 5507, Feb. 13, 1996] <br />ate Employee's Printed Name <br />Date Emolo r Repress tative's Printed Name <br />Employer Representative's Signature <br />