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r� -�r reer� qy <br /> ea �r� (tea�tc� <br /> JAN 0 7 2019 <br /> E V(RONME <br /> HEPATITIS B DECLINATION FOR PE ir <br /> , H�sE vrcEs rM <br /> Please print clearly. <br /> FIRST NAME: LAST NAME: <br /> 1 r 1 <br /> HEPATITIS B VACCINATION DECLINATION <br /> LJ I have not completed the Hepatitis B series of three (3) vaccinations. <br /> I understand that due to my potential for occupational exposure to blood or other <br /> potentially infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV) <br /> infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at <br /> my expense. However, I decline the Hepatitis B vaccination at this time. I understand that <br /> by declining the Hepatitis B vaccine I continue to be at risk of acquiring Hepatitis B as a <br /> serious disease. If, in the future, I continue to have occupational exposure to blood or other <br /> potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I <br /> can receive the vaccination series at that time. <br /> RESIDENT'S SIGNA DATE: <br /> WITNESS'S SIGNATURE(OSHA standards require the signature of a witness.): DATE: <br /> RESIDENT Hepatitis B Declination Form www.ggbha.org Reviewed 5/17/2017 <br />