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8:37 <br /> Done Hepatitis_B_Dedination_Stat... <br /> Hepatitis B Declination Statement <br /> 'rhe following statement of declination of hepatitis B vaccination must he 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 elticacy,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 8 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,1 can receive the vaccination series at no charge to me. <br /> Employee Name(print 1 'lin Niebla Rodriquez_ <br /> Employee Signature: / <br /> Date: 1110512020 <br /> IL <br /> UT <br />