Hepatitis B Declination

HEPATITIS B DECLINATION

I had appropriate training regarding hepatitis B, hepatitis B Vaccination, the efficiency, Safety, method of administration and benefits of vaccination, given free of charge to the employee.

I understand that my occupational exposure to patients, blood or other potentially infectious materials at healthcare facilities with the following vaccine preventable diseases puts me at risk of acquiring the disease. I have had the opportunity to be vaccinated, however, I choose to decline the vaccination(s) checked below at this time. I understand that by declining vaccine protection I continue to be at risk of acquiring the disease.

This statement is not a waiver; employees can request and receive the hepatitis B vaccination at later date if they remain occupationally at risk for hepatitis B.

An employer cannot require:

• Employees to waive liability in order to receive the vaccine.

• Participation in pre-screening as a prerequisite for receiving the vaccine.