Bloodborne Pathogens Exposure Control Plan

   Appendix C    

ICPH 

ICPH Subject Index

E.C.P.

Index

App A

App B

App D

Quiz

Hepatitis B Vaccine Declination-- Mandatory. 

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.

[Statutory Authority: Chapter 49.17 RCW.  92-08-100 (Order 92-01), § 296-62-08050, filed 4/1/92, effective 5/5/92.]

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Signature                                                                      Date

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Witness                                                                         Date

      (1-23-02)