Laserfiche WebLink
Hepatifis B Vaccine Declination <br /> I understand that, due to my occupational expor.,ure to blood or Other Potentially Infectious <br /> Materials (OPIM), 1 may be at risk of acquiring epatitis 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 thistime. 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 occupational exposure to 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 /> r <br /> v, <br /> a <br /> Dab- Employee's printed name E p be sign re <br /> Date Employer representative's printed name ErIlployer rep ntative's signature <br /> 96/66 39Vd dIHS '8 NOdd IQO-1 9Z80L96-60Z 5G:6T LTOZ/6Z/0T <br />