Biological Hazards – Infectious Diseases » Written Opinion For Hepatitis B Vaccination

Health Care Professionals

Written Opinion For Hepatitis B Vaccination*

  • 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: 



*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).