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Hapalftis 5 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 hepatftis 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 ofacquiringhepatitis B, a serious disease. If in the future I <br /> continue to have occupaltional exposure to blood or OPIM and I went to be vaccinated with the <br /> hepatitis B vaccine, I can receive the vaccination series at no charge to me. <br /> oq <br /> r1f 0LV l <br /> Date Employee's printed name 4 -t'mployee-s signature <br /> pate Employer representative's printed name RAployarfo)m <br /> ,,�ve's signature <br /> 96/96 39Vd dIHS ? ADVd IGO-1 9Z8OL96-60Z SP:CT LTOZ/CZ/OT <br />