Hepatitis Declination
Hepatitis B Vaccine Declination Form The following statement of declination of the hepatitis B vaccine must be signed by an employee who:
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 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. Employee Signature:___________________________Date:________________
An employer can not require:
|
![]() ![]() ![]() ![]() |