Laserfiche WebLink
Hepatitis B Vaccine Declination <br /> I understand that, due to my occupational exposure to blood or Other Potentially Infectious <br /> Materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been <br /> given the opportunity to be vaccinated with hep this 8 vaccine at no charge/cost to myself. <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 1 <br /> continue to have occupdhonal exposure to blood or OPIM and I want to be vaccinated with the <br /> hepatitis B vaccine, 1 can receive the vaccination series at no charge to me. <br /> s <br /> via/ <br /> Date Employee's printed name Em 'ssign <br /> ©/ f Z //-7 _7A-0 N60YEAI �- <br /> Date� Employer representative's printed name YqjKyer representative s signature <br /> 9£/0Z SJdd dIHS '8 AOVd IQ01 9Z80L9£-60Z 5b:£T LTOZ/£Z/0T <br />