Chawanakee USD | E 4319.42 Personnel
Exposure Control Plan for Bloodborne Pathogens
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.
Employee Name (Please print)
CHAWANAKEE UNIFIED SCHOOL DISTRICT
North Fork, California