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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 I may be at risk of acquiring hepatitis B virus infection. I have been given the <br /> opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However I <br /> decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I <br /> continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue <br /> to have occupational exposure to blood or other potentially infectious materials and I <br /> want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no <br /> charge to me. <br /> Signed: (Employee Name) <br /> Date: <br /> 22 <br />