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| I am looking for a Hepatitis B Vaccine Waiver that employee sign off when he/she declined the opportunity to be vaccinated.
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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. I have reviewed information on the risk associated with hepatitis B disease, availability and effectiveness of any vaccine against hepatitis B, a serious disease. 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.
At this time, I decline to have a hepatitis B vaccine.
______________________ _____________________
Employee Signature Date
Note: The statement of declination of Hepatitis B vaccinations is not intended to supersede or in any way affect any workers’ compensation law, common law, statutory rights, or duties or liabilities of employers and employees arising out of or in the course of employment.
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