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Student Hepatitis B Vaccine eeffir-kdo <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 P virus (HBV) infectious. <br /> However, I decline Hepatitis I3 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 R 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 /> eA <br /> have decided not to receive injections of <br /> (Print Name) <br /> c- <br /> Da Signature <br /> IAPolicy and Legal CHP\Health Forms,Crim Bkgrd Chcic, drug screen,fingerprint for Students\Health <br /> Forms 2011.2012\1-Iep B Vaccine Decline F orm.doc <br />