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Hepatitis B Declination Statement* <br />The following statement of declination of hepatitis B vaccination must be signed by an <br />practitioner who chooses not to accept the vaccine. The statement can only be signed by the <br />practitioner following appropriate training regarding hepatitis B, hepatitis B vaccination, the <br />efficacy, safety, method of administration, and benefits of vaccination. The statement is not a <br />waiver; employees can request and receive the hepatitis B vaccination at a later date if they <br />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 <br />materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the <br />opportunity to be vaccinated with hepatitis B vaccine; however, I decline hepatitis B vaccination <br />at this time. I understand that by declining this vaccine I continue to be at risk of acquiring <br />hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood <br />or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I <br />can receive the vaccination series at my discr <br />Employee Signature: Date: 07/12/2022 <br />*Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />