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ATTACHMENT <br /> OSHA Bloodborne Pathogen Hepatitis B Vaccination & Declination Form <br /> For Completion by the Em to ee: <br /> Employee Name \ <br /> Social Security # �►� 3 <br /> Department <br /> W ' r <br /> Date of Hire for new employees) <br /> I have participated in training provided by Hamilton College that addresses the OSHA regulations on bloodborne <br /> pathogens, universal precautions and the Hepatitis B vaccine. Further, I understand that Hamilton College will <br /> offer the Hepatitis B vaccine to me at no cost. <br /> At this time, my decision regarding the Hepatitis B vaccination is as indicated: <br /> ❑ Yes, I wish to receive the vaccination. I understand and commit to the full series of 3 injections. <br /> Employee Signature Date <br /> For Completion by the Provider Administering the Hepatitis B Vaccine: <br /> Dept. or Provider <br /> Administering the Vaccine: <br /> Employee Name <br /> Date of I " Shot <br /> Date of 2" Shot <br /> Date of 3" Shot <br /> Hepatitis B Vaccine Declination Statement <br /> Employee Waiver of Immunization <br /> ❑ No, I do not need to receive the vaccination because I am presently vaccinated for the HBV. (If known, <br /> please enter the date ofyour vaccination: ) Please sign below. <br /> 52ol o, I do not want to receive the vaccination. I understand that I may change my mind and receive the vaccine <br /> at a later date. (You must sign the declination statement below if you choose not to have the vaccination) I <br /> understand that due to my occupational exposure to blood and other potentially infectious materials, I may be at <br /> risk of acquiring HBV infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at <br /> no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this <br /> vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. I also understand that if in the future I <br /> continue to have occupational exposure to blood or other potentially infectious materials and I want to be <br /> vaccinated with Hepatitis B vaccine, I can receive the vaccination series at that time, at no charge to me. <br /> � 1 � 22- <br /> EmPee Signature Me <br />