Hepatitis B Declination Statement
E 4119.42
HEPATITIS B DECLINATION STATEMENT – Ketchikan Gateway Borough School District
The Ketchikan Gateway Borough School District has determined the following job classifications may have occupational exposure to blood borne pathogens.
|
Job Classification |
School/Location |
Location Defined |
|
School Nurse |
All |
|
|
Nurse’s Aide |
All |
|
|
Secretaries |
Some |
Positions that require student personal care or first aid care. |
|
Athletic Coaches |
All |
|
|
Special Services Personnel |
Some |
Teachers grades P-2 where student personal care is required. Parapro positions that require student personal care. |
|
Custodians/Maintenance |
Some |
Positions that require cleaning of bodily fluids/contact with bodily fluids. |
|
Para Professionals |
Some |
Positions that require student personal care. |
|
Physical Education Teachers |
All |
|
|
Science and Vocational Teachers |
Some |
Grades 7-12 if lab settings are part of instruction. |
As an employee of KGBSD in one or more of these classifications you have a potential to be exposed to blood and other infectious materials. As per Board Policy 4119.42 and Administrative Regulation 4119.42, you are entitled to a Hepatitis B vaccination at no cost. You may decline to accept the vaccination. If you choose to receive the Hepatitis B vaccination you need to contact the Director of Human Resources to arrange for vaccination procedures and options.
Hepatitis B Vaccination BP 4119.42
Hepatitis B vaccinations shall be provided at no cost to those employees determined to have occupational exposure to blood and other potentially infectious materials. Employees who decline to accept the vaccination shall sign the hepatitis B declination statement as required by law. (E 4119.42) (29 CFR 1910.1030 (f)(2))
Hepatitis B Vaccine Declination E 4119.42
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.
[ ] I decline the vaccination. [ ] I have already had the Hepatitis B Vaccine. Date: ____/____/____
[ ] I accept, and will schedule a time for the vaccination within the next 6 weeks.
______________________________________________ ____/____/______
Employee Signature Date
______________________________________________
Employee Name (Printed)
*Returning this form is a mandatory requirement. Return to your immediate supervisor or Human Resources.
Revision Date: 7/25/12