Laserfiche WebLink
Hepatffls 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 B 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, I can receive the vaccination series at no charge to me. <br /> s <br /> r� <br /> ado ve, <br /> Date Employee's printed namd E loyee's sign <br /> - <br /> Date Employer representative's printed name Employ ntative's signature <br /> 96/ZE 39Vd dIHS ? A0dd Ia0-1 9ZBOL96-60Z Sb:ET LTOZ/6Z/OT <br />