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Hospital eTool - Healthcare Wide Hazards-Health C4re Professionals He atitis B Declin... Page I of I -4 v A to Z Index I Newsroom I Contact Us I FAQs I About OSHA OSHA 0 SHARE M IF E3 Newsletter URSSFeeds Occupational Safety&Health Administration We Can Help What's New I Offices OSHA Home Workers Regulations Enforcement Data&Statistics Training Publications Newsroom Small Business Anti-Retaliation <<Back to Hosortal eTool-Healthcare Wide Hazards-Bloodborne Pathogens Health Care Professionals Hepatitis B Declination Statement Hepatitis B Declination Statement The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses riot 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 tater 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 a I want to be v cc ated with he i s B I can receive the vaccination series at no charge to me. Employee Signature* C!f!i N.,.,v w4 IF— Vate 'Taken from:Bloodbome Pathogens and Acute Care Facilities OSHA Publication 3128,(1992). Freedom of Information Act I Privacy&Security Statement I Disclaimers I Important Web Site Notices I international Contact Us U.S.Department of Labor I Occupational Safety&Health Administration 1 200 Constitution Ave.,NW,Washington,DC 20210 Telephone:800-321-OSHA(6742) 1 TTY www.OSHA.gov https://www.osha.gov/SLTC/etools/hospital/hazardsibbp/declination.htrnl 4/20/2018