The Hepatitis B declination form is OSHA’s mandatory statement that an employee at risk of bloodborne pathogen exposure signs when refusing the free Hepatitis B vaccine offered by the employer. The form must use word-for-word the language in Appendix A of 29 CFR 1910.1030, and it takes only two entries from the employee: a signature and a date. What surrounds those two entries is where employers get into trouble.1eCFR. 29 CFR 1910.1030 – Bloodborne Pathogens
The Exact Wording the Form Must Contain
The declination text is fixed by regulation. You cannot summarize it, reword it, translate its ideas into plainer English, or bury it inside a broader liability waiver. Copy the paragraph directly from the eCFR or OSHA’s published standard:
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.2eCFR. 29 CFR 1910.1030 — Bloodborne Pathogens
Below the paragraph, the regulation requires only two fields: a signature line and a date line. It does not require a printed name field, though many employers add one internally. Any paraphrase or omission is a citable violation.
What Must Happen Before the Employee Signs
A signed declination is not valid if the steps leading up to it were skipped. The standard sequences the process, and the order matters.
First, the employee must complete bloodborne pathogens training. OSHA does not allow you to offer the vaccine or collect a declination until training is done. The session must cover epidemiology and symptoms of bloodborne disease, modes of transmission, the employer’s written exposure control plan, proper use of personal protective equipment, emergency procedures for exposure incidents, and information on the Hepatitis B vaccine itself: its efficacy, safety, method of administration, benefits, and the fact that it is free to the employee.1eCFR. 29 CFR 1910.1030 – Bloodborne Pathogens Training must include a live opportunity for the employee to ask questions of the person conducting it. A click-through video alone does not satisfy the standard.3Occupational Safety and Health Administration. 1910.1030 – Bloodborne Pathogens
Second, the employer must actually offer the vaccine at no cost within 10 working days of the employee’s first assignment to duties with occupational exposure. The 10-day clock starts on the first day of the exposure-risk assignment, not the hire date. “At no cost” is interpreted broadly: the employee cannot pay for the vaccine, the associated medical evaluation, transportation to the provider, or the time spent getting the shots. Travel to the vaccination site counts as on-duty time.4Occupational Safety and Health Administration. Employer’s Responsibility To Provide Time and Transportation for Hepatitis B Vaccinations
Only after training has been delivered and the vaccine has been genuinely offered can the employee’s refusal be documented on the declination form. A form signed on day one, before training, is not a compliant declination.
Filling Out and Signing the Form
The mechanics are straightforward once the underlying steps are complete:
- Print the Appendix A paragraph on the form exactly as written, with no additions or edits to that block of text.
- Have the employee read the statement. If you have added a printed-name field, the employee prints their name.
- The employee signs on the signature line.
- The employee enters the date of signing on the date line.
The employee should sign personally. The regulation does not authorize a supervisor or HR staff member to sign on the employee’s behalf. Keep a clear log entry showing the training date, the date the vaccine was offered, and the date the declination was signed, so the sequence is provable.
Partial-Series Refusals
The Hepatitis B vaccine is given in three doses over six months. If an employee starts the series and later decides not to finish, OSHA has not published a separate form for that situation. Common practice is to have the employee sign the standard Appendix A declination, and to note in the confidential medical record which doses were completed and the date the employee declined to continue.
The Form Is Not a Permanent Waiver
The declination’s own language spells out that the employee can change their mind. As long as the employee still has occupational exposure, they can request and receive the full vaccination series at no cost at any point after signing.5Occupational Safety and Health Administration. Hepatitis B Declination Statement Reminding employees of this right during annual refresher training is a reasonable practice.
Where the Signed Form Goes
The completed declination becomes part of the employee’s confidential medical record, which must be kept separate from the general personnel file. It cannot be disclosed inside or outside the workplace without the employee’s express written consent, except as required by the standard or by law.1eCFR. 29 CFR 1910.1030 – Bloodborne Pathogens The employee has full access to their own record; OSHA inspectors and designated representatives authorized in writing by the employee can also access it.6Occupational Safety and Health Administration. Access to Employee Exposure and Medical Records
Retention is long. The employer must keep the signed declination for the duration of the employee’s employment plus 30 years.1eCFR. 29 CFR 1910.1030 – Bloodborne Pathogens For a 20-year employee, that is half a century of storage.
When No Declination Is Needed
Three situations remove the need for either vaccination or a signed declination: the employee has already completed the full Hepatitis B vaccine series, antibody testing shows they are already immune, or the vaccine is medically contraindicated for them. Document the reason in the confidential medical file. For prior vaccination or demonstrated immunity, the employer must obtain a written opinion from a licensed healthcare professional confirming whether vaccination is indicated, within 15 days of completing the evaluation.7Occupational Safety and Health Administration. Hepatitis B Vaccination Protection Antibody prescreening cannot be a condition of receiving the vaccine.
What Getting It Wrong Costs
A missing declination, an improperly worded one, or one signed before training was completed can all produce OSHA citations. As of January 2025, penalties reach $16,550 per serious or other-than-serious violation, $165,514 per willful or repeated violation with a minimum of $11,823 for willful violations, and $16,550 per day for failure to abate past the deadline.8Occupational Safety and Health Administration. OSHA Penalties A single inspection can generate stacked citations if the employer failed to train, failed to offer the vaccine, failed to collect a compliant declination, and failed to store the record confidentially. A chronological log tying each employee’s training date, offer date, and declination date together is the record that carries an employer through an unannounced visit.