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d <br /> Facility Name (PRINT) <br /> Practitioner Name (PRINT) <br /> Hepatitis B virus (HBV) Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been <br /> given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; <br /> however, I decline hepatitis B vaccination at this time. I understand that by declining this <br /> vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future <br /> I continue to have occupational exposure to blood or other potentially infectious materials <br /> and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series <br /> at no charge to me. <br /> OSHA's Bloodborne Pathogens Standard(29CFR 191 .1030 App A) <br /> Employee Signatur , Date: .3"i Zf r� <br />