1910.1030 Bloodborne Pathogen Standard - Appendix A HEPATITIS B VACCINE DECLINATION (MANDATORY)
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 not charge to myself. However, I decline
hepatisis B vaccination at this time. I understand that by
declining this vaccine I continue to be at risk of acquring
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.
The following statement of declination of the hepatitis B
vaccine must be signed by an employee who:
- Chooses not to accept the vaccine.
- Has had appropriate training regarding hepatitis B,
hepatitis B vaccination, the efficacy, safety, method of
administration and benefits of vaccination, given free of
charge to the employee.
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 hepatis B
vaccine, at no charge to myself. 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.
signed: employee___________________________
- This 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 hepatistis B.
An employer can not require:
- Employees to waive liability in order to receive the
vaccine
- Participation in pre-screening as a prerequisite for
receiving the vaccine.
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