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United States Department of Transportation United States Department of Transportation

Form FAA 3900-41 - FAA Hepatitis B Virus (HBV) Vaccination Consent/Decline Form

Document Information

Number
FAA 3900-41
Title
FAA Hepatitis B Virus (HBV) Vaccination Consent/Decline Form
Status
Active
Edition date
2023-11-09
Orientation
Portrait
Unit of issue
Electronic
Office of Primary Responsibility
AJW-23
Description

The Form's use is prescribed in the Bloodborne Pathogen Control Chapter of FAA Order 3900.19C (currently out for formal comment). (Note: Draft 3900.19C still references FAA Form 8020-22; however this will be changed once this form receives a number.)

The FAA Occupational Medical Surveillance (Occ Med) Program (now being stood up) covers all employees with ATO EOSH Services as the implementation organization. Ownership of the FAA Hepatitis B Vaccination Consent/Decline Form is being revised from AVS/AVP-100 to the FAA national OSH policy office (ATO EOSH Services). Further, the AVS/AVP-100 form was used as a starting point and was revised and updated with information from the Centers for Disease Control and Prevention and appropriate instructions on how to obtain Hepatitis B vaccination through the FAA Occ Med Program. The Form also includes information on where to send the form if declining Hepatitis B vaccination, to ensure the form makes it into an employee's 'Employee Medical Folder' or 'EMF', which is maintained by the FAA Occ Med Program.

This form was developed to contain specific information required by Occupational Safety and Health Administration (OSHA), including Personally Identifiable information (PII), specifically an employee's Social Security Number (SSN). The form is also used to document Hepatitis B vaccination information (such as date, vaccine-specific lot information, who administered the vaccination). This form must be filed in an employee's EMF, which is maintained by the FAA Occ Med Program.

EMFs are a type of personnel record and are covered under the following System of Record: OPM/GOVT-10, "Employee Medical File System Records." The Form includes the notification and citation regarding the inclusion of the SSN in the form.

AJW-235 Manager: Tom Holloway, 202-267-6170, Tom.Holloway@faa.gov

Contact information
Paul DiBenedetto
paul.dibenedetto@faa.gov
202-267-6177
Content