Skip to main content Skip to footer site map

FormsStaffHealth/Safety → Mandatory Hepatitis B Vaccine Declination Statement

Mandatory Hepatitis B Vaccine Declination Statement

(Confidential)

About this Form

Form number: 230-31

Audience:  MCPS Staff

Last revised: July 2012

INSTRUCTIONS: Complete this form and send one copy to the Systemwide Safety Programs Unit and one copy to the Employee and Retiree Service Center (ERSC) .

Note: All medical records shall be kept confidential and may not be disclosed or reported without the employee's expressed written consent to any person within or without the workplace except as required by law, but may be reviewed and copied by the employee who is the subject of the file. Questions regarding the Bloodborne Pathogens program may be directed to the Systemwide Safety Programs Unit, 240-314-1070.

Adobe PDF Mandatory Hepatitis B Vaccine Declination Statement
(Confidential)
75 KEnglish

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat

Click here to log in