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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*For more information, see: Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications Standards. OSHA Publication 3186 (2003), 521 KB PDF, 29 pages.
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