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<br />San Joaquin County
<br />Environmental Health Department
<br />• East Flazelton
<br />Stockton, California 95205�6232
<br />�1 Pahza3millp
<br />W�bsaie0 www sjgov.org/N7
<br />Phone: (209) 468-3420
<br />Fax; (209) 4640138
<br />Hepatitis B Declination Statement'A
<br />D1RC=CTOR
<br />Linda Turkatte, REHS
<br />PROGRAM COOK©lIVA70RS
<br />Robert McClellon, REHS
<br />Jeff Carruesco, REHS, RDI
<br />Kasay Foley, REHS
<br />Rodney Estrada, REHS
<br />Adrienne Ellsaesser, REHS
<br />.,, 't " _.
<br />The fallawuig 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 given the
<br />opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; however, I decline
<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 infectious materials and I want to be vceinated with
<br />hepatitis B vaccine, I can" ive the vaccination series at no charge tome,
<br />Employee Signature: _ Date:
<br />�Talcen fiom: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992).
<br />San Joaquin County
<br />Environmental Health Department
<br />• East Flazelton
<br />Stockton, California 95205�6232
<br />�1 Pahza3millp
<br />W�bsaie0 www sjgov.org/N7
<br />Phone: (209) 468-3420
<br />Fax; (209) 4640138
<br />Hepatitis B Declination Statement'A
<br />D1RC=CTOR
<br />Linda Turkatte, REHS
<br />PROGRAM COOK©lIVA70RS
<br />Robert McClellon, REHS
<br />Jeff Carruesco, REHS, RDI
<br />Kasay Foley, REHS
<br />Rodney Estrada, REHS
<br />Adrienne Ellsaesser, REHS
<br />.,, 't " _.
<br />The fallawuig 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 given the
<br />opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; however, I decline
<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 infectious materials and I want to be vceinated with
<br />hepatitis B vaccine, I can" ive the vaccination series at no charge tome,
<br />Employee Signature: _ Date:
<br />�Talcen fiom: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992).
<br />
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