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Transcript
337 Maine Avenue, Farmingdale, ME 04344 Tel: (207) 582-3110 ♦ Fax: (207) 582-3112 ♦ TF: (800) 525-2229 ♦ www.skcdc.org NAME: _____________________________ DATE: ____________________ HEPATITIS B VACCINE Occupational exposure to hepatitis B is addressed in OSHA’s Bloodborne Pathogen standard, 29 CFR 1910.1030. As stated in the standard, “The employer shall make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post exposure evaluation and follow–up to all employees who have had an exposure incident.” 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 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. I have received the hepatitis B vaccination series. Date: ____________ Date: ____________ Date: ____________ Signature: __________________________________ Date: ________________ 7.22.16 Head Start ♦ Early Head Start ♦ Child Care ♦ Child and Adult Care Food Program Child Care Options / Resource Development Center A United Way Member Agency An Equal Opportunity/Affirmative Action Employer