- To inform each employee at time of hire of the federal Occupational Safety and Health Administration (OSHA) standards related to the Hepatitis B vaccination.
Consumer Directed Services (CDS) is funded by the Texas Health and Human Services Commission (HHSC) to operate a program involving direct contact with an individual. The employer is obligated to adopt and implement workplace guidelines similar to guidelines adopted by HHSC and the Texas Department of State Health Services HIV/AIDS Model Workplace Guidelines.
- To document the employee's acknowledgment for the receipt of and understanding of the information documented on this form.
- To document the employee's choice to receive or to decline the Hepatitis B vaccination.
- To document the mandated declination statement required by OSHA for each employee.
When to Prepare
The employer will review this form with each employee on or before the hire date. The employee will complete, sign and date the Certification by Employee statement. The employer will sign and date acknowledging the employee's choice regarding receipt or declination of the Hepatitis B vaccination.
If the employee declines the vaccination, but later decides to accept the vaccination, the employer and the employee complete a new Form 1727. The initial Form 1727 is maintained in the personnel file in addition to the new form.
Number of Copies
Original and one copy.
The employer keeps the original in the employee's personnel file and gives a copy to the employee. If the employee accepts the vaccination, submit a copy of page 2 to the Financial Management Services Agency (FMSA) attached to the employee's Form 1730, Wage and Benefits Plan Employee Compensation.
The employer must keep this form while in effect, plus five years after termination of the employee's employment or until all outstanding litigation, claims and audits are resolved.
The employee initials and dates after each statement.
Employee Statement — The employee checks one statement that identifies the employee’s choice regarding the Hepatitis B vaccination. Choices include:
- I agree to receive the Hepatitis B vaccination and will be reimbursed by my employer within 30 days of presenting a paid receipt for each dose. I understand that I will only be reimbursed for doses received while employed by the employer.
- I agree to receive the Hepatitis B vaccination and the employer and I have agreed to the following arrangement(s) related to covering the cost of the vaccination: *____________________________________________________
* Examples of payment arrangements may include:
- the health care provider administers the vaccination and submits an invoice to the employer for processing, which the employer then submits to the FMSA for payment directly to the provider; or
- the employer pays for the vaccination out-of-pocket and receives a "paid" receipt from the health care provider, which the employer then submits to the FMSA for reimbursement.
- I decline the Hepatitis B vaccination at this time because I have previously received the Hepatitis B vaccination.
- I decline the Hepatitis B vaccination. [Mandatory Declination Statement from OSHA included.]
Certification by Employee — The employee certifies by signing and dating this form. The employee acknowledges that information about "universal precautions" and "Hepatitis B vaccination" was reviewed. The employer signs acknowledging the employee's statement to either agree to accept or to decline the Hepatitis B vaccination.
The employee prints his name in the blank in the certification statement (I, _______,).
The employee prints and signs his name below the statement. The employee enters the date of his signature.
The employer prints and signs below the statement to acknowledge the employee's choice related to the Hepatitis B vaccination and, if accepted by the employee, the employer acknowledges the payment arrangements for the vaccination. The employer dates the signature.