OSHA Hepatitis Vaccine Occupational Exposure to Blood Borne Pathogens O.S.H.A. regulation states that all health care professionals with occupational exposure to blood borne pathogens must be offered the hepatitis B vaccinations. You have been determined to be at risk to blood borne pathogens.Please indicate: I have already received the hepatitis B vaccine. (I will submit a copy of titer level to NLS, Inc.) I decline the hepatitis B vaccine. If interested in the hepatitis B vaccine, I may contact either my local county health department or a provider of my choice at my own expense. If declining: I understand that due to my occupational exposure to blood or other potentially infections 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 my own expense. 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 occupation exposure to blood or other potentially infectious materials and I want to vaccinated with hepatitis B vaccine, I can receive the vaccination series at my own expense.Name First M.I. Last DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Agreement I agree and understand.
