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Hepatitis B vaccine declination form (free OSHA template)

Last reviewed November 7, 2026  ·  2 sources

Short answer

A hepatitis B vaccine declination form is the statement an employee signs when they turn down the hepatitis B vaccine their employer offers. OSHA requires it under the Bloodborne Pathogens Standard, and the wording must match Appendix A exactly.

Download the free form below. It has OSHA's wording, signature lines and a section for the office to record when the vaccine was offered.

The required OSHA wording

This is the full statement from 29 CFR 1910.1030 Appendix A, which OSHA marks as mandatory. Don't edit it. You can add fields around it.

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.

Free printable declination form

Hepatitis B vaccine declination (mandatory)

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Required wording from OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030, Appendix A.

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.

For the office

Keep the signed form with the employee's confidential hepatitis B vaccination records. OSHA requires that medical record, including vaccination status, to be kept for the duration of employment plus 30 years (29 CFR 1910.1030(h)(1)). An employee who declines can still get the vaccine later at no cost while their exposure continues.

Open the printable version or use the download button.

When to use the form

Use it when an employee with occupational exposure to blood or other potentially infectious materials is offered the hepatitis B vaccine and declines it. In a dental office that usually means dentists, hygienists, assistants and anyone who cleans or sterilizes instruments.

The rules for the offer come first. Under 29 CFR 1910.1030(f), you must:

  1. Give the employee bloodborne pathogens training, including information on the vaccine's efficacy, safety, method of administration and benefits, and that it is free.
  2. Offer the vaccine series within 10 working days of their initial assignment to tasks with exposure.
  3. Make it available at no cost to the employee, at a reasonable time and place, performed by or under a licensed healthcare professional.
  4. If they decline, have them sign the declination statement.

Who doesn't need to be offered the vaccine

The offer isn't required when the employee:

  • has already received the complete hepatitis B vaccine series,
  • has antibody testing that shows they are immune, or
  • can't have the vaccine for medical reasons.

Record which of these applies. The declination form is only for an employee who is offered the vaccine and says no.

If the employee changes their mind

An employee who declined can ask for the vaccine later. If they still have occupational exposure, you must make it available at that time, at no cost. Keep the original declination with the new vaccination dates.

How long to keep the form

Keep the signed form with the employee's confidential hepatitis B vaccination records. OSHA requires the employee medical record, which includes vaccination status, to be kept for the duration of employment plus 30 years. Keep it separate from the general personnel file.

Questions

Is the hepatitis B declination form required by OSHA?

Yes. Under 29 CFR 1910.1030(f)(2)(iv), an employee with occupational exposure who declines the hepatitis B vaccine the employer offers must sign the statement in Appendix A of the Bloodborne Pathogens Standard.

Can I change the wording of the declination?

No. Appendix A is marked mandatory, so the statement must use OSHA’s wording. You can add fields around it, such as the date the vaccine was offered or a witness line.

When do I have to offer the hepatitis B vaccine?

Within 10 working days of the employee’s initial assignment to tasks with occupational exposure, after they have received the bloodborne pathogens training, and at no cost to the employee.

What if the employee was already vaccinated?

OSHA does not require you to offer the vaccine to someone who has already had the complete series, whose antibody testing shows immunity, or who cannot have it for medical reasons. Record which applies; the declination form is for employees who turn the offer down.

Can an employee change their mind after declining?

Yes. If they still have occupational exposure and later decide to get the vaccine, the employer must make it available at that time, at no cost to them.

Sources

  1. OSHA: 29 CFR 1910.1030, Bloodborne Pathogens Standard
  2. OSHA: 29 CFR 1910.1030 Appendix A, Hepatitis B Vaccine Declination (Mandatory)