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.
*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).