Health Care Professionals
Written Opinion For Hepatitis B Vaccination*
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- Employee Name:______________________________________________
- Date of Office Visit:___________________________________________
- Health Care Facility Address: ___________________________________
- Health Care Facility Telephone: ___________________________________
As required under the bloodborne pathogen standard:
- Hepatitis B vaccination is ____ is not ____ recommended for the employee named above.
The employee named above is scheduled to receive the hepatitis B vaccination on
the following dates:
- First of three ___________
- Second of three_________
- Third of three___________
Signature of health care provider:____________________________________
Printed or typed name of health care provider:__________________________
This form is to be returned to the employer, and a copy provided to the employee within 15 days.
Employer Name:______________________________
Title:_______________________________________
Address:_________________________________________________________
*For more information, see : Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications
Standards. OSHA Publication 3186 (2003), 521 KB PDF, 29 pages.
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