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I undensiand that due to my occupational exposure,to blood Or Other I)OIeWililly illfVC6011S <br /> malerial-,I may be at risk of accl"Iring. or transmitting Hepatitis B virus (IIBV) infectiolls. <br /> Flowever, I clecline Tlepatil is B vaccination at this time. I understand that b�, declinim-- <br /> tills vaccine. I continue to be at risk of acquiring I lepatilis B. a serious clusease. If, In the <br /> I'LI11,11'e. I COVIIiII11C 10 have Occapational exposilre to blood or other potentially Infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, 1 may do so. <br /> Reference: Appendix A- 29 Code of Federal Regulations 1910.1030 Occupational <br /> Z� <br /> HApostire to Bloodborne Pathogens. Occupational Safety 1111d,licaltil Act. <br /> have.decided uO to receive Injections of <br /> (Print Name) <br /> alr Sianature <br /> 1APolicy and Legal CH11\1-fealift Forms,Crhn Bkord Click,(tru-sci-mu,fingi-rprim for StudentAl leal III <br /> Norms 2011.2(312\1-left R Vaccine Decline Form.doc <br />