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Ram I � DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 Cornucopia Way,Suite C,Modesto,CA 95358-9492 <br /> Phone:209.525.6700 Fax:209.525.6774 <br /> www.stancounty.com <br /> my <br /> Strivinq !a ht !+te Best <br /> Hepatitis B Vaccination Declination Form <br /> In accordance with OSHA requirements emalovers must make hepatitis B vaccinations available at no <br /> cost to employees who have an occupational exposure to the hepatitis B virus (HBV). Body art <br /> practitioners are required to submit evidence of current hepatitis B immunity in conjunction with <br /> registration materials This includes records of hepatitis B vaccinations and boaster shots. if a <br /> practitioner declines to be vaccinated against HBV he/she must submit a signed declination <br /> agreement from his/her emolover. A sample declination statement its provided below. Contact <br /> Occupational Safety&Health Administration(www osha.goy)for additional information. <br /> Waiver of Hepatitis B Vaccine <br /> "I L i7Af ,0 Crloi v�G Z understand that due to my occupational exposure to blood <br /> Other Potentially Infectious Materials(OPIM),I may be at risk of acquiring hepatitis B virus(HBV) <br /> infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine,at no charge to <br /> 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.if in the future I <br /> continue to have occupational exposure to blood or or OPIM and I want to be vaccinated with hepatitis <br /> B vaccine,I can receive the vaccination series at no charge to me." <br /> [56 FR 64004,Dec.06,1991,as amended at 57 FR 12717,April 13,1992;57 FR 29206,July 1, 1992;61 <br /> FR 5507, Feb.13,1996] <br /> Li7oi <br /> Date Employee's Printed Name Employee's Signature <br /> 00h XA <br /> Date Employer Representative's Printed Name Employer Representative's signature <br />