Download Hepatitis B Vaccine Form 7.22.16

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337 Maine Avenue, Farmingdale, ME 04344
Tel: (207) 582-3110 ♦ Fax: (207) 582-3112 ♦ TF: (800) 525-2229 ♦
NAME: _____________________________ DATE: ____________________
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: ________________
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