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- Hep B Declination Statement

Last Updated: 10/24/2012

Following is the Hep B Declination Statement excerpted from the OSHA website, the fact that there IS one, should alert you to the availability of opting out.  If your employer requires the Hep B series, just ask for the OSHA opt-out form, and if they cannot (read won't) supply it, feel free to copy/paste/print from here.

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:____________________ 


*Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992).

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