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4P <br /> Student 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 or transmitting Hepatitis B virus (HBV) infectious. <br /> However, I decline Hepatitis B vaccination at this time. I understand that by declining <br /> this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the <br /> future, I continue to have occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I may do so. <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> VG r 1-0 have decided not to receive injections of <br /> (Print Name) <br /> 21-7 I <br /> Date Signature <br /> �- L <br /> I:APolicy and I-egal CHP\Health Forms,Crim Bkgrd Click, drug screen,fingerprint for StudentsUlealth <br /> Forms 20t1.20.12\IIep B Vaccine Decline For-m.doc <br />