Osha Printable Hepatitis B Vaccine Declination Form For Completion by the Provider Administering the Hepatitis B Vaccine Dept or Provider Administering the Vaccine Employee Name Date of 1st Shot Date of 2nd Shot Date of 3rd Shot Hepatitis B Vaccine Declination Statement Employee Waiver of Immunization No I do not need to receive the vaccination because I am presently vaccinated for the HBV
Instructions This form fulfills OSHA s Bloodborne Pathogen Standards requirement for Hepatitis B vaccination Complete each section and submit the completed form along with any accompanying vaccination records to the Department of Environmental Health Safety and Risk Management PART I VACCINATION REVIEW OR DECLINATION Form FAA 3900 41 Hepatitis B Virus HBV Vaccination Consent Declination Form is issued by the FAA Occupational Medical Occ Med and BBP Programs Designated Agency Safety and Health Official DASHO Support Group AJW 25 and is required by the FAA Exposure Control Plan ECP
Osha Printable Hepatitis B Vaccine Declination Form
Osha Printable Hepatitis B Vaccine Declination Form
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06 02 22 Publication ID 34906 This information sheet discusses the policies and standards of the Occupational Safety and Health Administration OSHA concerning hepatitis B and the provisions made for workers who may have occupational exposure to blood or other potentially infectious materials It explains the duty of the employer to develop Hepatitis B Vaccination Declination Form INSTRUCTIONS Every employee covered by the OSHA Bloodborne Pathogens Standard must complete EITHER this declination form OR the Hepatitis B Vaccination consent form and return it to the Safety and Risk Management Office
A high percentage of healthy people who receive three doses of this vaccine achieve high levels of surface antibody HBsAb and protection against Hepatitis B Full immunization requires three does of vaccine given over a six month period Universal Hepatitis B Vaccination in Adults Aged 19 59 Years Updated Recommendations of the Advisory Committee on Immunization Practices United States 2022 Hepatitis B Vaccination of Infants Children and Adolescents ACIP Recommendations Healthcare Personnel Vaccination Recommendations 1 page Posted Jul 2008
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ACCEPTANCE understand that due to my occupational exposure to blood or other potentially infectious materials that may be at risk of being infected by bloodborne pathogens including Human Immunodeficiency Virus HIV and Hepatitis B Virus HBV Hepatitis B virus HBV Declination Statement 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
Hepatitis B Vaccination Reference OSHA Bloodborne Pathogens Standard Code of Federal Regulations CFR 29 CFR 1910 1030 I understand that due to my occupational exposure to blood or other potentially infectious materials OPIM I may be at risk of acquiring Hepatitis B virus HBV infection PART 1 HEPATITIS B VACCINATION FORM OSHA states that the hepatitis B Virus vaccination shall be offered to all employees occupationally exposed to blood or other potentially infectious materials unless the employee has a previous HBV vaccination or unless antibody testing has revealed the employee is immune OSHA recommends
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https://www.hamilton.edu/documents/HepatitisBVaccination-DeclinationForm.pdf
For Completion by the Provider Administering the Hepatitis B Vaccine Dept or Provider Administering the Vaccine Employee Name Date of 1st Shot Date of 2nd Shot Date of 3rd Shot Hepatitis B Vaccine Declination Statement Employee Waiver of Immunization No I do not need to receive the vaccination because I am presently vaccinated for the HBV
https://www.sfasu.edu/docs/safety/bbp-vaccine-declination-form.pdf
Instructions This form fulfills OSHA s Bloodborne Pathogen Standards requirement for Hepatitis B vaccination Complete each section and submit the completed form along with any accompanying vaccination records to the Department of Environmental Health Safety and Risk Management PART I VACCINATION REVIEW OR DECLINATION
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Osha Printable Hepatitis B Vaccine Declination Form - 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
