Hepatitis B Vaccine Declination

The following statement is taken from Title 29 Code of Federal Regulations (CFR), Appendix A to Section 1910.1030 ? Hepatitis B Vaccine of the Occupational Safety and Health Administration regulation on bloodborne pathogens.

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.

Signed: (Employee Name) ______________________________________ Date: _________________

Supervisor's Signature: _________________________________________ Date: _________________