Hepatitis B vaccine declination form for NEMT drivers: OSHA's required wording and where to file it

This is the form a driver or attendant signs when they turn down the hepatitis B vaccine your company must offer them. It applies only to employees whose jobs involve reasonably expected contact with blood, such as cleaning a bleeding rider’s seat or giving first aid. Which of your staff fall in that group is decided in the exposure control plan, and the wider rules are in the OSHA guide for NEMT companies. Whether you may make the vaccine a condition of the job is a separate question, answered in the guide to requiring vaccines. This page holds the form, the offer record behind it, and the filing rules.

When does the offer have to be made?

Training comes first, and the offer follows within 10 working days of the employee’s first assignment to exposed work. The standard says to make the vaccine available after the employee finishes the bloodborne pathogens training, and no later than 10 working days after initial assignment. Work through these steps in order:

1. Finish the training. It must include information on how well the vaccine works, how safe it is, how it is given, the benefits, and that it is free.
2. Check for a reason to skip the offer. The employee may have already completed the series, antibody testing may show immunity, or a doctor may have ruled the vaccine out. Put the proof in the medical record, because OSHA’s directive wants any claimed exemption documented there.
3. Arrange the first dose. OSHA reads “made available” to include the clinician’s evaluation and setting up the first dose to start within the 10 days. Part-time and temporary employees are included.
4. Do not require a blood test first. The standard bars making prescreening a condition of getting the vaccine. You may offer the test free if you wish.
5. Make the offer and let the employee choose. An employee who accepts needs no declination. An employee who declines signs the statement below on the spot.

The vaccine visit normally happens during scheduled work hours, and when the clinic is away from the worksite the employer pays for the travel, according to OSHA’s directive.

The form

Part A: The offer

Part B: The employee’s choice (check one)

The declination statement (OSHA’s mandatory wording)

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Employee name (print): __________ Signature: __________ Date: __________

Part C: If the employee changes their mind

Part D: Filing

Can you change OSHA’s wording?

Yes, but only in ways that help the employee understand it. OSHA lets an employer use different words if they carry the same information. Any addition should exist only to improve comprehension, and a form that adds language discouraging the vaccine or raising liability concerns is not acceptable. California’s mandatory statement reads “blood or OPIM” where the federal text spells out “other potentially infectious materials,” and employers there use that version.

Leave these off the form, because OSHA’s directive treats each as a problem:

• A required reason or medical details. A form that makes the employee give confidential medical information, whether on the declination or a separate sheet, can draw a citation under the paragraph that keeps medical records confidential. A mandatory “reason” line can slide into that.
• A waiver of liability. A release for harm caused by the vaccine conflicts with the rule that the vaccine be free.
• A promise to repay. The directive prohibits making the employee pay first and be reimbursed after staying for a period of time, and prohibits a contract that has the employee repay the cost when leaving before a set date.
• A requirement to use the driver’s own insurance. It is allowed only when the employer pays all of the premium and the employee owes no deductible, copayment, or other cost.
• An exaggerated description of the risks. A consent form that overstates the hazards conflicts with the training requirement, which asks for accurate information about safety and benefits.

A form for people who accept can ask for ordinary informed consent. It cannot carry any of the items above.

How long do you keep a signed declination?

Keep it in the confidential medical record, which OSHA requires for the length of the employee’s employment plus 30 years. The standard says each exposed employee’s record holds a copy of the hepatitis B vaccination status, including the dates of all vaccinations. A signed declination records that status, so it belongs in the same file. OSHA’s own model plan leaves a blank for the place where the documentation of refusal is kept, so name the place in your exposure control plan.

• Short-term employees. The record of an employee who worked less than a year need not be kept past the end of the job if you hand it to the employee on leaving.
• Confidentiality. The record may not be disclosed without the employee’s written consent, except as the standard or other law requires. The employee, or anyone the employee names in writing, can get a copy on request.
• Training records. These are separate and last three years from each session. They are covered in the record retention guide.

What happens after the driver says yes

The vaccine, the clinic visit, and any follow-up are free to the employee, and a licensed physician or other licensed health care professional performs or supervises them. The clinician’s written opinion for the vaccine is limited to whether it is indicated and whether the employee got it. CDC’s guidance for health care personnel recommends an antibody test 1 to 2 months after the third dose, and a level of 10 mIU/mL or higher counts as immune. Someone below that level gets a second series and another test. OSHA’s FAQ adds that the employer cannot require the follow-up blood test, so offer it and record the answer.

Tracking the dates in HealthRide

The offer and the yearly refresher are dated items for each exposed driver. In HealthRide, any credential with an expiration date can sit on the driver’s profile with a reminder ahead of it, which suits the training date that has to come before the offer and the refresher a year later. Keep the vaccination record itself in the separate confidential medical file, not on a dispatch screen. Setup is on the fleet and credentials page.