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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), 1 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 occupandonal 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 /> C;�I) 'r -0,QA4,CA4,, <br /> Date Employee's printed name Employee's Signa re <br /> A14 0 <br /> Date Employer representative's printed name E plover repntatve's signature <br /> 96/96 39vd dIHS ? ADdd IQO-1 9Z80L96-60Z 5b:6T LT0Z/6Z/0T <br />