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Hospital eTool - HealthcareWe Hazards - Health Care Professionalspatitis B Declin... Page 1 of 1 <br /> ;_SEARCH <br /> A to,' + - ii,, FAQs i About OSHA <br /> OSHA IFINg } Newsletter O"RSS Feeds GP;int This Page Text Size "Was this page helpful? <br /> Occupational Safety& Health Administration We Can Help What's New i Offices <br /> Home Workers Regulations Enforcement Data&Statistics Training Publications Newsroom Small <br /> OSHABusiness <br /> <<Back to Hospital eTool-Healthcare Wide Hazards-Bloodborne Pathogens <br /> Health Care Professionals Hepatitis B Declination Statement <br /> Hepatitis B Declination Statement` <br /> The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine.The statement can only be <br /> signed by the employee following appropriate training regarding hepatitis B,hepatitis B vaccination,the efficacy,safety,method of administration,and benefits of <br /> 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 <br /> hepatitis B 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 infectious materials I may be at risk of acquiring <br /> hepatitis B virus(HBV)infection.I have been given the opportunity to be vaccinated with hepatitis B vaccine,at no charge to <br /> me;however,I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of <br /> acquiring hepatitis B,a serious disease.If,in the future I continue to have occupational exposure to blood or other potentially <br /> infectious materials and nt to be vacci ted t 'th hepatitis B vaccine,I can receive the vaccination series at no charge to me. <br /> Employee Signature: Date: Z /Z <br /> `Taken from:Bloodborne Pathogens and Acute Care Facilities.OSHA Publication 3128,(1992). <br /> Pr-rJnfn of information Act I Privacy&Socunty Statement I Disclaimers I Customer Survey Impoi <br /> U.S.Department of tabor I Occupational Safety&Health Administration 1200 Constftutbn Ave.,NW,Washington,IX 7nJ in <br /> Telephone:800-321 OSHA(6742) 1 TTY:877-889-5627 <br /> www.OSHA.gov <br /> http://www.osha.gov/SLTC/etools/hospital/hazards/bbp/declination.htmi 10/25/2012 <br />