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San Joaquin County Environmental Health Department DIRECTOR Linda Turkatte,RENS 1868 East Hazelton Avenue X PROGRAM COORMATORS Stockton, California 95205-6232 Robert McClellon,RENS Jeff Carruesco,RENS,RD] ce� Website:www.sjgov.org/eh d Kasey Foley,RENS ji 6,0 Rodney Estrada,RENS Phone: (209)468-3420 Addenne Ellsaesser,RENS Fax: (2 8)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 rete' I pw the vaccination series at no charge to me. -A Employee Signa ture:_< Date: U *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128,(1992).