Environmental Health & Safety	EH&S TEL NO: (818) 677-2401 FAX NO: (818) 677-5853 MAIL DROP: 8284
	Hepatitis B Vaccine Declination Form

California State University, Northridge, is required by law to assure that employees who decline to accept the hepatitis B vaccination offered by the University, sign the following statement as required by California Code of Regulations, Title 8, section 5193, subsection (f) (2) (D):

I understand that, due to my occupational exposure to blood or other potentially infectious materials (OPIM), 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 the hepatitis B vaccine 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 (OPIM), and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

(Authority Cited: SECTION 142.3 AND 144.7, Labor Code)

1. I have been advised that, in the course of my employment as a with California State University, Northridge, I may be exposed or have the potential for exposure to hepatitis B Virus (HBV).

2. The risks associated with receiving or not receiving the vaccination have been explained to me.

Employee's Last Name:	Employee's First Name:	CSUN ID Number:
Position Title:	Department:	Telephone:

Employee Signature: __________________________________

Date:____________