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s ° <br /> DIRECTOR <br /> ?•' =r``—C '®G ` Linda Turkatte, REHS <br /> PROGRAM COORDINATORS <br /> StrockLcn, Cal"'Ifo-t`G�Cc� Robert McClellon,REHS <br /> a <br /> g Jeff Carr co REHS RDI <br /> 4. <br /> Kasey Foley, REHS <br /> GO,'0 Rodney Estrada, REHS <br /> (20--nI 4.63-3420 Adrienne Ellsaesser, REHS <br /> Fax: (201091) 464-0133 <br /> Hepatitis B Declination Statement` <br /> The following statement of declination of hepatitis B vaccination must be signed by an <br /> employee who chooses not to accept the vaccine. The statement can only be signed by the <br /> employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the <br /> efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and <br /> vaccination are provided free of charge to the employee. The statement is not a waiver; <br /> employees can request and receive the hepatitis B vaccination at a later date if they remain <br /> occupationally at risk for hepatitis B. <br /> Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquirin;;hepatitis B virus (HBV) infection. I have been given the <br /> opportunity to hp.vacrinaterl ;vitit hepatitis B va_.c.inP at nn rb irorP t^ ire• hn;t aver T ripolim- <br /> hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be <br /> at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational <br /> IT <br /> exposure to blood or other potentially infectious materials anu i want to be vaccinated with <br /> hepatitis B vaccine, I capeiVeive t ccination series at no charge to me. <br /> Employee Signatur : DateA-2 ` �6 <br /> `Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />