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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 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 /> ©! 12/1:Z �� I <br /> Date Employee's printed name Employ s 'nhfijm <br /> lot ( Z/l7 Two A97UVgAl <br /> Date Employer representative's printed name E oyer re tive's signature <br /> 96/b6 39dd dIHS W A0dd IQOI 9380L96-603 5p:6T LT03/63/0T <br />