New Jersey Department of Health

PEOSH Unit

HEPATITIS B DECLINATION 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 want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Name of Employee (Print)

Signature of Employee	Date

OCC-8

JAN 13

OCC-

OCT 08	29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904. The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.

OCC-8, Hepatitis B Declination Statement

occ-8, hepatitis b, declination statement, PEOSH, occupational health, OCC

ewhite

2009-02-23

NJDOH