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Hepatiti's 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 <br /> 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. The <br /> statement is not a waiver; employees can request and receive the hepatitis B vaccination <br /> 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 futu-re I continue to have occupational exposure to blood 1 <br /> or other potentially infectious materials and I want to be vaccinated with hepatitis B <br /> vaccine, I can receive the vaccination series at no charge to me. <br /> ,Employee Name (print)- <br /> r7J <br /> "Employee Signatur <br /> -e- <br /> Date: <br />