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11, a U, n NC-0,ul n t <br /> -h D DIRECTOR <br /> Linda Turkatte, REHS <br /> U <br /> FFCC <br /> 866' East �Kazelton Aven lue <br /> PROGRAM COORDINATORS <br /> Robert McClellon, REHS <br /> rrue� <br /> jeff C.- sco, REHS, RD! <br /> Kasey Foley, REHS <br /> Z'i Rodney Estrada, REHS <br /> Phoiie. (20S),4-58-3420 Adrienne Ellsaesser, REHS <br /> Fax: (2-009) 4,64-01138 <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 acquirin hepatitis B virus (HBV) infection. I have been given the <br /> 0Fp-)—o: nit-y to be vanc-c-inated with hi-.-nntitiq R vnrrinp, at i1r) rhT-cy <br /> qp to mi-- hm?,,rever, T -1 r.r li n t- <br /> . <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 vaccinated with <br /> hepatitis B vaccine, I can receive the vaccin�ti in series at no charge to me. <br /> Employee Signature�-Z�—/,l-,-,--.-,---" Date: h(A <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />