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San Joaquin County Environmental Health Department DIRECTOR Linda Turkafte,REHS 1868 East Hazelton Avenue PROGRAM COORDINATORS U): Stockton, California 95205-6232 Robert McClellon,REHS Jeff Carruesco,REHS, RDI CWebsite:vvvA4,�sjgov.org1ehd Kasey Foley,REHS i�, 6WPRodney Estrada,REHS hone209 : ( )468-3420 Adrienne Ellsaesser, REHS Fax: (209) 464-0138 Hepatitis B Declination Statement* The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination,the efficacy, safety,method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B. Declination Statement I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; however, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vacci ion s ries at no charge to me. ii Employee Signature: t cajo,M-1 ate: *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992).