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Chawanakee USD  |  E  4319.42  Personnel

Exposure Control Plan for Bloodborne Pathogens   

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HEPATITIS B VACCINE DECLINATION

In accordance with 8 CCR 5193 and 29 CFR 1910.1030, the district makes the hepatitis B vaccine available to employees who may reasonably be expected to have contact with blood or other potentially infectious materials in the performance of their duties. Any employee who declines this vaccine is required to read and sign the following statement:

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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Employee Name (Please print)

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Signature

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Date

Exhibit CHAWANAKEE UNIFIED SCHOOL DISTRICT

version: September 15, 2020 North Fork, California