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I understand that due to my occupational exposure to blood or other potentially infections: <br /> materials I may be at ride of acquiring or transmitting Hepatitis B virus (HBV)infcctious, <br /> However,i decline ITepatitis B vaccination at this time. I understand that by declining <br /> this vaccine. I continue to be at risk of acquiring Hepatitis B; a serious disease, If. in the <br /> future, I continue to leave occupational exposure to blood or other potentially infeetious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I Jnay do so. <br /> Reference; Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Wealth Act. <br /> I,l/C�Utt_l have decided not to receive injections of <br /> (Print Name) <br /> Date SinnaIII rc <br /> I.1I'olicy and Legal CHP\l-leaith Forms,Crim 131-,ord Chck,drug screen,fingerprint for StudentsUltaltlr <br /> loans 20J 1.2012\1-lep B Yaccine Decline rorni.doc <br />