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DEPARTMENT OF ENVIRONMENTAL RESOURCES <br />3800 Cornucopia Way, Suite L, Modesto, CA 95358-9492 <br />Phone: 209.525.6700 Fax:209.525.6774 <br />Hepatitis i3 Vaccination Declination Form <br />www.stancounty.com <br />In accordance with OSHA requirements employers must make hepatitis B vaccinations available at no <br />cost to employees who have an occupational exposure to the hepatitis B virus (HBV) Body art <br />practitioners are required to submit evidence of current hepatitis B immunity in coniunction with <br />registration materials. This includes records of hepatitis B vaccinations and booster shots. If a <br />practitioner declines to be vaccinated against HBV, he/she must submit a signed declination <br />agreement from his/her employer. A sample declination statement is provided below. Contact <br />Occupational Safety & Health Administration (www.osha.gov) for additional information. <br />Waiver of Hepatitis 8 Vaccine <br />"I �llzi(i� 'garKS • understand that due to my occupational exposure to blood <br />Other Potentially Infectious Materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) <br />infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to <br />myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this <br />vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I <br />continue to have occupational exposure to blood or or OPIM and i want to be vaccinated with hepatitis <br />B vaccine, I can receive the vaccination series at no charge to me:' <br />[56 FR 64004, Dec. D6, 1991, as amended at 57 FR 12717, April 13,1992; 57 FR 29206, July 1, 1992; 61 <br />FR 5507, Feb. 13,1996] <br />�A .1611 Aloki vlx'nrk,5 <br />Date Employee's Printed Name <br />•2G2I Carrie Blubaugh <br />Date Employer Representative's Printed Name <br />Employee's Signature <br />Employer Representative's Signature <br />