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Health Care Professionals
Written Opinion For Hepatitis B Vaccination*
  1. Employee Name:______________________________________________
  2. Date of Office Visit:___________________________________________
  3. Health Care Facility Address: ___________________________________
  4. 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:______________________________



*This form was taken from: Model Exposure Control Plan for Home Care: A Guide for Hospice/Home Agencies on the Bloodborne Pathogens Standards. OSHA Office of Occupational Nursing, (1994).