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 hepatitis B vaccination at a later
date if they remain occupationally at risk for hepatitis B.
Declination
Statement
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. I understand that by declining this vaccine I
continue to be at risk of acquiring hepatitis B, a serious
disease. If, in the future I 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:_____________________________ Date:____________________
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*Taken from:Bloodborne Pathogens and
Acute Care Facilities OSHA Publication 3128, (1992).
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