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Castro Valley USD |  E  4119.42  Personnel

Exposure Control Plan For Bloodborne Pathogens   

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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 myself.

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Signature

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Employee Name (Please print)

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Date

Exhibit CASTRO VALLEY UNIFIED SCHOOL DISTRICT

version: August 29, 2013 Castro Valley, California

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Exhibit 2

4119.42

4219.42

4319.42

EXPOSURE CONTROL PLAN FOR BLOODBORNE PATHOGENS

MASTER LIST OF EMPLOYEES WHO HAVE HAD BLOODBORNE PATHOGENS TRAINING

Name Position Training Dates Trainer Session

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_________________________________________________________________

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_________________________________________________________________

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Exhibit CASTRO VALLEY UNIFIED SCHOOL DISTRICT

version: September 11, 2003 Castro Valley, California

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E(3

4119.42

4219.42

4319.42

EXPOSURE CONTROL PLAN FOR BLOODBORNE PATHOGENS

Bloodborne Pathogens - Employee Record

Name:________________________________________SS#__________________

Position:_______________________________Site:_____________________

Vaccination Record: ____________

____________

____________

____________

Check off for the following Actions/Attachments:

_____ A. Examination, Testing, Follow-Up Procedures

_____ B. Information Provided To Health Care Professional

_____ C. Copy of Health Care Professional's Opinion

Training:

Date Session's:

________ ___________________________________________________________

________ ___________________________________________________________

________ ___________________________________________________________

Other Information:

Exhibit CASTRO VALLEY UNIFIED SCHOOL DISTRICT

version: September 11, 2003 Castro Valley, California