HEPATITIS B VACCINE DECLINATION
CSUCI Bloodborne Pathogen Exposure Program
As required by California Code of Regulations, Title 8, section 5193, subsection (f)(2)(D), California State
University Channel Islands is required to assure that employees who decline the Hepatitis B vaccination
offered by the University sign the following statement:
I understand that due to my occupational exposure to blood or other potentially infectious materials, I
may be at risk for acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with the 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
and I want to receive the Hepatitis B vaccine, I can receive the vaccination series at no charge to myself.
(Note: Authority cited - Sections 142.3 and 144.7, Labor Code)
I have been advised that in the course of my employment with California State University Channel
Islands, I may be exposed to the Hepatitis B virus.
The risks associated with receiving or not receiving the vaccination have been explained
to me.
EMPLOYEE NAME (PLEASE PRINT)
POSITION/ TITLE
EMPLOYEE SIGNATURE
DATE
Copy to Environment, Safety, Risk Management
