BLOODBORNE PATHOGEN STANDARD
VACCINATION DECLINATION FORM
EMPLOYEE NAME:_____________________________________DATE:___________ (please print)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 this vaccine 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 the Hepatitis B vaccine, I can receive the vaccination series at not charge to me.
EMPLOYEE SIGNATURE________________________________DATE___________ MANAGEMENT SIGNATURE______________________________DATE___________