EMPLOYEE ACKNOWLEDGMENT

OF

RECEIPT OF BLOODBORNE PATHOGEN TRAINING

Company Name:

I, hereby acknowledge receipt of training with regard to ’s Bloodborne Pathogens Exposure Control Plan. Specifically, I have been instructed to identify the job classification and associated tasks that place me at risk for exposure. Further, I understand how to protect myself through the use and implementation of specific engineering controls, work practices, personal protective equipment and clothing, housekeeping procedures, and labeling and disposal requirements. Finally, I understand that the company offers, at no cost to me, a Hepatitis B vaccination, and if I decline the vaccination, I am required to sign the "Hepatitis B Vaccine Declination" form. I may, however, change my mind at some future date and will be provided the vaccination at that time.

Training was received on this day of, Year

Employee Signature Date

Trainer's Signature Date