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Dental Office OSHA
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Hepatitis B declination form (free, printable)

This hepatitis B declination form uses the wording from 29 CFR 1910.1030 Appendix A. Type your office name, then print one copy for each employee who declines the vaccine.

when to use it

When must the hepatitis B vaccine be offered?

Within 10 working days of initial assignment, after the employee's bloodborne pathogens training, to each employee with occupational exposure 29 CFR 1910.1030(f)(2)(i). The vaccine and the vaccination series are made available at no cost to the employee, at a reasonable time and place 29 CFR 1910.1030(f)(1)(ii). A prescreening program cannot be a condition for the vaccine 29 CFR 1910.1030(f)(2)(ii).

See every other OSHA requirement in the guide to OSHA requirements for dental offices.

Questions about the declination form

Who must sign the hepatitis B declination?

Each employee who declines the hepatitis B vaccine offered by the employer signs the Appendix A statement 29 CFR 1910.1030(f)(2)(iv). The employer offers the vaccine to every employee with occupational exposure 29 CFR 1910.1030(f)(1)(i).

Can we change the declination wording?

Use the Appendix A text as written. OSHA marks the appendix mandatory 29 CFR 1910.1030 Appendix A. The rule text has no signature or date line, so a form may add them. This form adds the employee name, signature and date.

Can an employee accept the vaccine after declining?

Yes. If an employee declines and later decides to accept while still covered by the standard, the employer makes the vaccine available at that time 29 CFR 1910.1030(f)(2)(iii).

When is the vaccine offer not required?

In three cases: the employee already received the complete hepatitis B vaccination series, antibody testing shows the employee is immune, or the vaccine is contraindicated for medical reasons 29 CFR 1910.1030(f)(2)(i).