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Facility ID# <br /> Program ID# <br /> Hepatitis B Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I <br /> have read and understand the health risks involved with Hepatitis B; however, I <br /> voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br /> transmission and have full knowledge of its effects on the human body. I understand <br /> that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br /> disease. <br /> SIGNATURE: DATE: <br /> PRINT NAME:404NM C <br /> ADDRESS: <br /> .3 CITY: 60,L STATE ZIP clJe <br /> W,De.1EH4,ROGRAMS&PROJECTSWy AR OOCMMSpATrrj8 a DECLINATION STATEMENT,4 23 13AOM <br />