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�Yu�en�Y R�elsaYi6i5 %� �lacari�e �eclilaaYioll <br />I understand that due to my occnpaGonal exposure to Ulood or other• potentially infections <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 />fu Cure, I continue to have occupational exposure to blood or other potentially infections <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 OccnpaCional <br />Exposure to Bl00 Orrnfe Pathogens. Occupational Safety and Health Act. <br />I, er✓) r' tL ' ✓/►'► C`W( ��� , have decided not to receive injections of <br />(Frhu Name) <br />Dale <br />Signahne <br />I;�Policy and Legal C1iP\Health Forms,Crim Bl:bnd Chcic, drug screen, fiugerrgiint for Students4TTealtli <br />Forms 2011.20121t-Iep RVaccine Decline l+onn.doc <br />