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DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 Cornucopia Way,Suite C, Modesto, CA 95358-9492 <br /> Phone:209.525.6700 Fax: 209.525.6774 <br /> www.stancounty.com <br /> wity <br /> st"11,19 to pe the Bes, <br /> Hepatitis B Vaccination Declination Form <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 conjunction 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 B Vaccine <br /> "1 C—o I(`6Ina— 1[10 r<t�7 � 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.06, 1991,as amended at 57 FR 12717,April 13, 1992; 57 FR 29206,July 1, 1992; 61 <br /> FR 5507, Feb. 13, 19961 <br /> Date Employee's Printed Name Employee's Signa <br /> Carrie Blubaugh U <br /> Date Employer Representative's Printed Name Employer Representative's Signature <br />