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Hepatitis B Vaccine Declination Form <br /> Use vmh Chapter /296-823 V'v'AC, Occu,pallonal Exposure to Bloodborne Pathogens <br /> Facia Name: OC . dQ f <br /> T � <br /> Facility <br /> C OS OIC*i e•s <br /> I understand that due to my occupational exposure to blood or other potentially <br /> Infectious materials(OPIM), I may be at risk of acquiring hepatitis B virus(HBV) <br /> Infection. <br /> You have given me the opportunity to be vaccinated with the hepatitis B vaccine, at <br /> no charge to myself. <br /> However, I decline hepatitis B vaccination at this time. l understand that by declining <br /> this vaccine, I continue th be at risk of acquiring hepatitis B, a serious disease. If, <br /> In the future, I continue to have occupational exposure to blood or other potentially <br /> infectious materials,and I want to be vaccinated with hepatitis B vaccine, I can <br /> receive the vaccination series at no charge to me. <br /> I have already received the hepatitis B vaccination series. <br /> � 'a, P. <br /> ►S <br /> Employ, "s Name <br /> EmAs Sig <br /> oo i hq <br /> Date <br /> http://www, Ini.wa.gov/ <br /> R-b <br /> 09104 <br />