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; WWW.Osha.gov1SLTC/etoolsilhospital./hazardsi'` b " Eric Miil€kith, Noirth �(olLl —"'confirms unicorn fair; preq.. € pita Toci1 w Healthcare Wide Hazards - Heal � � OSHA • :. 1 a' r' G O F ,.� * Was this pap helpful' Occupational Safety & Health Administration We Can Help What's New t Offices Home- Workers R"utetkona Enforcement DOW & Statistics Training PuMkcetions NewsroomOSHA tc Back. to Hospital eTaol - Healthcare Wide Hazards - Bloodbame Pathogens Health Care Professionals Hepatitis B Declination Statement Hepatitis B Declination Statement 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 signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy. safety, method of administration. and benefits of 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 hepabbs B vaccination at a later date if they remain occupationally at risk for hepatitis B. Declination Staternent I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me, however. I decline hepatitis B vaccination at this time. 1 understand that by declining this vaccine I continue to be at nsk of acquiring hepatitis B. a serious disease. If. in the future 1 continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee Signature:' data: Taken from: Bloodborne Pathogens and Acute Care Facdits. OSHA Publication 3128, (1992).