topleft CSBA.org >  Services >  Governance Technology > 

Delano Joint HSD  |  E  4319.42  Personnel

Exposure Control Plan for Bloodborne Pathogens   

arrow Previous bar Next arrow

Hepatitis B Vaccine Declination

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 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.

___________________________________

Signature

___________________________________

Employee Name (Please print)

___________________________________

Date

DELANO JOINT UNION HIGH SCHOOL DISTRICT

Delano, California