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SUdr&Hepatitis B Vaccine Declination <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV)infectious. <br /> However,T decline I-lepatitis.B vaccination at this th-ne. 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 have occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I may do so. <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> -T <br /> I <br /> have decided not to receive injections of <br /> (Kint Name) <br /> /71 <br /> Date Si nature <br /> 1APolicy and Legal CHMealth Forins,Crim Bkgrd Chek,drug screen,fingerprint for StudentsUlealth <br /> Forms 2011.2012\Hep B Vaccine Decline Forin.doc <br />