Hepatitis B Vaccine Declination (Mandatory)
The hepatitis B vaccine declination statement is used if an employee declines the vaccination. This must be signed by the employee and kept on file as part of the employee's records.
I understand 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: ________________
Model Exposure Control Plan
Here is a model Exposure Control Plan based on the samples provided throughout this module. You can use this to help you create your own companies ECP.
Sample Exposure Control Plan (PDF)
Knowledge Check Choose the best answer for the question.
4-12. Which of the following is TRUE if an employee declines to take a hepatitis B vaccination?
You forgot to answer the question!