Free printable template · PDF
Hepatitis B Vaccine Declination Form
The form an employee signs when they decline the hepatitis B vaccine you've offered. It uses OSHA's required wording exactly, has space for both signatures, and includes a section to record the vaccine series if the employee changes their mind later.
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Hepatitis B Vaccine Declination Form
MedSpaBinder
Clinic / employer
Employee name
Job title
The statement below is OSHA's required wording (29 CFR 1910.1030, Appendix A). Don't change it.
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.
Employee signature
Date
Employer representative (name and signature)
Date
Before signing, the employee has (employer confirms):
Completed bloodborne pathogens training, including the hepatitis B vaccine, its safety and benefits, and that it's free
Been offered the vaccine at no cost, at a reasonable time and place
If the employee later accepts the vaccine
Date employee asked for the vaccine
Recorded by
Keep in the employee's confidential medical record for the length of employment plus 30 years.
When you need this form
OSHA's Bloodborne Pathogens Standard requires employers to offer the hepatitis B vaccine, at no cost, to every employee with occupational exposure to blood or other potentially infectious materials. It must be offered after the employee has had bloodborne pathogens training and within 10 working days of their starting the job.
An employee can decline. If they do, OSHA requires them to sign the declination statement in Appendix A of the standard. That wording is mandatory, which is why it's printed here exactly as OSHA publishes it.
How to use it
- Offer the vaccine after training and within 10 working days of the employee starting.
- If they decline, have them sign and date the form, and sign it yourself.
- If they change their mind later while still exposed, OSHA requires you to provide the vaccine then, still at no cost. Record the doses in the table.
- File the form in the employee's confidential medical record. Most clinics keep medical records apart from the personnel file.
Who doesn't need to sign
Employees who have already completed the hepatitis B vaccine series, whose antibody testing shows immunity, or for whom the vaccine is medically contraindicated don't have to be offered it again, so they don't sign a declination. Record their vaccination status in their medical record instead.
Questions
Can I change the wording of the declination?
No. OSHA's standard requires the Appendix A statement. You can add your clinic's details, signatures and dates around it, as this form does, but the statement itself should be used as written.
How long do I keep a signed declination?
It's part of the employee's medical record under the Bloodborne Pathogens Standard, which OSHA requires you to keep for the duration of employment plus 30 years.
Sources
- OSHA, 29 CFR 1910.1030 Appendix A (Hepatitis B vaccine declination)
- OSHA, Bloodborne Pathogens Standard, 29 CFR 1910.1030
General guidance, not legal or medical advice. Requirements vary by state; follow your medical director and product labels.