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9-6()3F I Z_ yj u 7/.f <br /> Addendum L. <br /> OSHA Hepatitis B Declination Statement <br /> When the waiver Is signed,no words may be added or deleted to the exemption.IT MUST <br /> BE EXACTLY AS WORDED BELOW.Copy the form,print,sign and turn In to your <br /> employee. Found at: <br /> http•//www osha gov/SLTC/etools/hospital/hazards/bbpldeclination.html <br /> The following statement of declination of hepatitis B vaccination must be signed by an employee <br /> who chooses not to accept the vaccine.The statement can only be signed by the employee <br /> following appropriate training regarding hepatitis b,hepatitis b vaccination, the efficacy, safety, <br /> method of administration,and benefits of vaccination, and that the vaccine and vaccination are <br /> provided free of charge to the employee. The statement is not a waiver;employees can request <br /> and receive the hepatitis b vaccination at a later date if they remain occupationally at risk for <br /> hepatitis b. <br /> Declination Statement: 1910.1030 App A <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 vaccinated with <br /> hepatitis B vaccine, I can receive the vaccination series at no charge to me. <br /> he <br /> Employee Signature: <br /> Date: <br /> Employer Signature: <br /> Date: <br /> r <br />