OSHA Hepatitis B Declination Form


OSHA Hepatitis B Declination

When the waiver is signed, no words may be added or deleted to the exemption. It must be exactly as worded below. Copy the below, print, sign and turn in to your employee.

Hepatitis B Declination Statement (http://www.osha.gov/SLTC/etools/hospital/hazards/bbp/declination.html)

The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. The statement is not a waiver; employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for 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 me; 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.


Signature:_____________________________ Date:____________________

If the employee chooses to receive the Hepatitis B vaccine, they must sign an informed consent release. Some employers have tried to add language to the consent form that relieves them from responsibility in the event that an adverse reaction occurs that is related to the vaccine. OSHA regulations do permit a liability waiver to be added to these forms. OSHA states that its role in these matters is as follows:
“OSHA does not have the authority to determine liability for injuries or illnesses; such liability is a matter of state worker’s compensation or tort law. We do, however, have the responsibility to ensure that employees who have occupational exposure to blood or other potentially infectious materials are offered the hepatitis B vaccine at no cost.” [1]

If an employee refuses the vaccination because he has had previously received the Hepatitis B series, documentation should be included in the employee’s medical file, if at all possible. Serum testing for Hepatitis B antibodies does not necessarily prove previous vaccination. Vaccine-induced antibodies to HBV decline gradually over approximately 7 years and nearly 60% of persons who initially respond will lose detectable antibodies within 12 years. [2] If obtaining the documentation it is not feasible, the employee can still sign the mandatory declination form.

The CDC recommends that testing for the anti-HBs is done approximately one to two months after the completion of the vaccination series, as anti-HB levels are most accurately detectable for the first 30-60 days. Antibody testing is not clinically recommended after a six-month period, as the reliability of the antigen as a true marker to differentiate between a recent HBV infection or the vaccination is not as accurately portrayed. [3]

1. OSHA Standard Interpretations 05/03/2000 – Application of 1910.1030 (HBV vaccination series) to police, firefighters, and accident investigators.http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=23780&p_text_version=FALSE
2. MMWR December 26, 1997, 46(RR-18);1-42
3. OSHA Regulations. Ibid.