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0 <br /> Stan/ <br /> 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 /> lty <br /> sitrving to pa tho B651 <br /> Hepatitis B Vaccination Declination Form <br /> In accordance with OSHA requirements employers must make hepatitis B vaccinations available at no <br /> cost to employees who have an occupational exposure to the hepatitis B virus IHBV). Body art <br /> practitioners are required to submit evidence of current hepatitis B immunity in coniunction with <br /> registration materials This includes records of hepatitis B vaccinations and booster shots. If a <br /> practitioner declines to be vaccinated against HBV he/she must submit a signed declination <br /> agreement from his/her employer. A sample declination statement is provided below. Contact <br /> Occupational Safety&Health Administration(www osha gov)for additional information. <br /> Waiver of Hepatitis B Vaccine <br /> f` <br /> L��'} � 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 /> k . <br /> Date Employee's Printed Name Employee's Signature <br /> t � 1 �.--� k� �i <br /> 1,4 <br /> (��+n Cw.nl n..nr Dnnrnrnn+++n.nr Or:n+nrl/l\t-.rrn Cr..n n..nr Dnnrnrnn+-++n.nir Cinn�+..rn <br />