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San Joaquin County <br /> DIRECTOR <br /> Environmental Health Department <br /> Uncle Turkatle,REHS <br /> 1868 East Hazelton Avenue <br /> PROGRAM COORATO <br /> N. Stockton, Callfomia 95205-6232 <br /> Robed McClellonDIN,REHS RS <br /> Jeff Carruesoo,REHS.RDI <br /> cq Website:www.sjgov.org1ehd Kasey Foley,REHS <br /> •.•,,...W Rodney Eshvia,REHS <br /> Phone: (209)468-3420 Addenne Ellsmsser,REHS <br /> Fax: (209)464-0138 <br /> Hepatitfs 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 to if they remain <br /> occupationally at risk for hepatitis B. <br /> Declination Statement <br /> jiS <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.�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 /> Employee Signature.—Q ful"a -'P��Date- I 113 0 j I (V 1 <br /> *Taken from:Bloodborne Pathogens and Acute Care Facilities.OSHA Publication 3128,(1992). <br />