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Health Care Professionals
Written Opinion For Hepatitis B Vaccination*
The employee named above is scheduled to receive the hepatitis B vaccination on
the following dates:
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.
*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).