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 hepatitis 5 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 I <br /> continue to have occupdbonal 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 /> Date Employee's printed name Empioy ria re <br /> g,Ad IQ G u Y15&1 <br /> Date Employer representative's printed name E oyer represen nature <br /> 96/T6 39Vd dIHS ? ADVd IQO-1 9Z80L96-60Z Sb:6T LTOZ/6Z/0T <br />