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HEPATITIS B VACCINATION DECLINATION FORM MANDATORYFor use in this dental office/practice/facilityI understand that, due to my occupational exposure to blood or otherpotentially infectious materials, I may be at risk of acquiring Hepatitis Bvirus (HBV) infection. I have been given the opportunity to bevaccinated with Hepatitis B vaccine, at no charge to myself. However,I decline Hepatitis B vaccination at this time. I understand that bydeclining this vaccine, I continue to be at risk of acquiring Hepatitis B,a serious disease. If in the future I continue to have occupational exposureto blood or other potentially infectious materials and I want to bevaccinated with Hepatitis B vaccine, I can receive the vaccination seriesat no charge to me.Employee signatureDateOSHA EXPOSURE CONTROL PLAN…a member benefit from the WDA 24
POST-EXPOSURE EVALUATION AND FOLLOW-UPFor use in this dental office/practice/facilityIn this Dental Office/Practice/Facility: When an employee receives an occupational exposure to blood or other potentially infectiousmaterial, first aid (e.g., clean the wound, flush the eyes or other mucous membrane) is administered assoon as feasible. All exposure incidents that occur are reported, investigated and documented.When the employee incurs an exposure, it is reported to:(Name of assigned staff person or employer)(Name of assigned staff person or employer) Following a report of an exposure incident, the exposed employee will immediately, or as soon aspossible (within 24 hours) be referred to the appropriate contracted health care provider for follow up.(Name, phone number, address of contracted health care provider)THE ABOVE STATED CONTRACTED HEALTH CARE PROVIDER will ensure that the exposedemployee will immediately, or as soon as possible, receive a confidential medical evaluation and followup including all of the following elements:Documentation of the routes of exposure and how the exposure incident occurred• Identification and documentation of the source individual, unless it can be established thatidentification is infeasible or prohibited by state or local law• The source individual’s blood shall be tested as soon as feasible and after consent is obtained inorder to determine Hepatitis B virus (HBV), Hepatitis C virus (HCV) and HumanImmunodeficiency Virus (HIV) infectivity• If the source individual is already known to be HBV, HCV and/or HIV positive, further testingneed not be performed• The health care provider must assure that the exposed employee is provided with the sourceindividual’s test results while complying with all laws protecting confidentiality of the source andexposed individualsOSHA EXPOSURE CONTROL PLAN…a member benefit from the WDA 25
Page 4 and 5: TABLE OF CONTENTSHEPATITIS B VACCIN
Page 6 and 7: EXPOSURE CONTROL PLAN, PURPOSE AND
Page 8 and 9: EXPOSURE DETERMINATIONDEFINITIONOSH
Page 10 and 11: EXPOSURE DETERMINATION FORMFor use
Page 12 and 13: ENGINEERING AND WORK PRACTICE CONTR
Page 14 and 15: NEEDLESTICK SAFETY AND PREVENTION A
Page 20 and 21: PERSONAL PROTECTIVE EQUIPMENTThe pe
Page 22 and 23: PERSONAL PROTECTIVE EQUIPMENT CONTI
Page 24 and 25: HOUSEKEEPING CONTINUEDC. IN-HOUSE L
Page 26 and 27: HEPATITIS B VACCINATION AND ANTIBOD
Page 30 and 31: POST-EXPOSURE EVALUATION AND FOLLOW
Page 32 and 33: OCCUPATIONAL EXPOSURE INCIDENT REPO
Page 34 and 35: INFORMATION AND TRAININGIn this Den
Page 36 and 37: OSHA BLOODBORNE PATHOGENS STANDARD
Page 38 and 39: RECORD KEEPINGIn this Dental Office
Page 40 and 41: APPENDIXEMPLOYER REFERENCE PAGESOCC
Page 42 and 43: APPENDIXThe Hepatitis B vaccine doe
Page 44 and 45: APPENDIXEMPLOYER FREQUENTLY ASKED Q
Page 46 and 47: APPENDIXWEB SITES FOR REFERENCE DOC
Page 48 and 49: APPENDIXOSHA EXPOSURE CONTROL PLAN
Page 50 and 51: APPENDIXONLY FOR EMPLOYERS HIRING M
Page 52 and 53: OSHA EXPOSURE CONTROL PLAN…a memb

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