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L ^i -" ,A <br /> 1 <br /> Hepatitis Declination Statement <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 <br /> by the employee following appropriate training regarding hepatitis B, hepatitis B <br /> vaccination, the efficacy, safety, method of administration, and benefits of vaccination, <br /> and that the vaccine and vaccination are provided free of charge to the employee. <br /> The statement is not a waiver; employees can request and receive the hepatitis B <br /> vaccination at a later date if they remain occupationally at risk for hepatitis B. <br /> Declination Statement <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 B vaccine, at no <br /> charge to me; however, I decline hepatitis B vaccination at this time. I understand <br /> that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a <br /> serious disease. If, in the future I continue to have occupational exposure to blood <br /> or other potentially infectious materials and I want to be vaccinated with hepatitis B <br /> vaccine, I can receive t e vaccina "o series at n charge to me. <br /> d <br /> I" <br /> Employee Signatur : <br /> Date: <br /> 'Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br /> Vis•//www osha gov/SLTC/etools/hospital/hazards/bbp/declination html <br />