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OCCUPATIONAL EXPOSURE / INJURY LOG <br /> Employee/Technician: <br /> Address: <br /> CONTACT NUMBER: <br /> DATE OF INJURY: <br /> BRAND AND TYPE OF DEVICE INVOLVED: <br /> LOCATION/WORK AREA where incident occurred: <br /> EXPLANATION OF HOW INCIDENT <br /> OCCURRED: <br /> HEPATITIS 8 VACCINE DECLINATION (MANDATORY) <br /> I understand that due to my occupational exposure to blood or <br /> other potentially infectious materials 1 may be at risk of acquiring <br /> hepatitis B virus(HBV) infection. I have been given the opportunity <br /> to be vaccinated with hepatitis B vaccine, at no charge to myself. <br /> However, I decline hepatitis B vaccination at this time. I understand <br /> that by declining this vaccine, I continue to be at risk of acquiring <br /> hepatitis B,a serious disease. If in the future I continue to have. <br /> occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated with hepatitis B vaccine, I can <br /> receive the vaccination series at no charge to me. <br /> Signed: (Employee Name) Date: <br />