"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."
You can find more information about the United States Public Health Service recommendations for hepatitis B vaccination athttp://www.cdc.gov/ncidod/diseases/hepatitis/b/ index.htm.
Helpful tool:
Sample declination form:
The declination form can help you document employees who have declined the hepatitis B vaccine. You can find a copy of this form in the resource section of this chapter.
Wash. Admin. Code § 296-823-13005
Statutory Authority: RCW 49.17.010, 49.17.040, 49.17.050, and 49.17.060. 04-12-070, § 296-823-13005, filed 6/1/04, effective 9/1/04; 03-09-110, § 296-823-13005, filed 4/22/03, effective 8/1/03.