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Hepatitis B Vaccine Declination Form <br /> The following statement of declination of the hepatitis B vaccine must be signed by <br /> an employee who: <br /> • Chooses not to accept the vaccine. <br /> • Has had appropriate training regarding hepatitis B,hepatitis 8 vaccination, <br /> the efficacy,safety, method of administration and benefits of vaccination, <br /> given free of charge to the employee. <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials I may be at risk of acquiring hepatitis B virus(HBV) infection.I <br /> have been given the opportunity to be vaccinated with hepatitis 8 vaccine, at no <br /> charge to myself. However, I decline hepatitis B vaccination at this time. I <br /> understand that by declining this vaccine I continue to be at risk of acquiring <br /> hepatitis 8,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 <br /> vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge <br /> to me. <br /> Employee Signature: Date: < <br /> —J/ <br /> • <br /> 7 <br /> This statement is not a waiver; employees can request and receive the <br /> hepatitis B vaccination at a later date if they remain occupationally at risk for <br /> hepatitis B. <br /> An employer can not require: <br /> • Employees to waive liability in order to receive the vaccine <br /> • Participation in pre-screening as a prerequisite for receiving the vaccine. <br />