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Hepatitis B vaccine declination form, ready to print
Type the employer and the employee, and get a one-page hep B declination form with the wording OSHA prints in Appendix A of 29 CFR 1910.1030. Nothing you type leaves your browser.
- Exact Appendix A wording
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Hepatitis B Vaccine Declination (Mandatory)
- Employer
- ____________________
- Employee name
- ____________________
- Job title
- ____________________
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.
Keep the signed form in the employee's confidential medical record for the length of employment plus 30 years. An employee who declines can ask for the vaccine at any time while still working in a job with exposure, and the employer must then provide it at no cost.
The Appendix A declination wording
Appendix A to 29 CFR 1910.1030, "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.
What the declination form is
When an employee has occupational exposure to blood, the employer must offer the hepatitis B vaccine series at no cost. Some employees say no: they were already vaccinated and cannot find the record, they would rather go to their own doctor, or they simply do not want it yet. When an employee declines, the standard requires the employer to have them sign a declination statement, and the wording is printed in Appendix A to 29 CFR 1910.1030, headed "Hepatitis B Vaccine Declination (Mandatory)".
The form this page makes uses that wording, word for word, with the employer's name, the employee's name and job title at the top and a signature and date line at the bottom.
When the vaccine has to be offered
The vaccine must be made available within 10 working days of an employee's initial assignment to a job with occupational exposure, after the employee has had bloodborne pathogens training. The exceptions are an employee who has already completed the series, whose antibody test shows immunity, or for whom the vaccine is medically contraindicated.
An employer may not make a medical screening or a blood test a condition of getting the vaccine. Vaccination and any needed booster, and the evaluations that go with it, are at no cost to the employee and at a reasonable time and place.
Declining is not final
An employee who declines can change their mind at any time while still working in a job with occupational exposure. The employer must then provide the vaccine at no cost. The wording on the form says so: if the employee later wants the vaccine, they can receive the series at no charge.
Where the signed form goes
The signed declination belongs in the employee's confidential medical record, kept for the length of employment plus 30 years under 29 CFR 1910.1020, and not shared without the employee's written consent except as the law requires. It does not belong in the open binder with the written Exposure Control Plan.
The declination is one part of a larger duty. The employer also needs a written Exposure Control Plan that says how the vaccine is offered, training, a post-exposure procedure and records. Gloveplan's plan builder writes that plan from your answers.
Source: 29 CFR 1910.1030 on osha.gov.
FAQ
Common questions
Is the wording the official OSHA text?
Yes. The statement is the text printed in Appendix A to 29 CFR 1910.1030. The form around it (name, job title, signature, date) is Gloveplan's layout. OSHA does not approve forms or tools; the standard says employees who decline must sign the Appendix A statement.
What is the hep B declination form for?
It is the signed statement an employee gives when they are offered the hepatitis B vaccine for a job with occupational exposure to blood and decline it. The standard prints the required wording in Appendix A to 29 CFR 1910.1030.
Is this legal advice?
No. Gloveplan is a document tool, not legal or safety advice. Check the standard and your state's rules for your workplace.
Can the employee sign on screen?
The form is made to print and sign by hand, or to sign in a PDF viewer. Gloveplan does not collect or store signatures.
Do I need one form per employee?
Yes, one signed form for each employee who declines. Make as many as you need: change the employee name and download again.
Are my names stored?
No. The employer and employee names are used on your device to print the PDF and are never sent to our server.
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Need the whole written plan too?
The declination is one form. Employers with exposed employees also need a written Exposure Control Plan. Build yours from your own answers and preview it free.