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Facility ID# <br /> Program ID# <br /> Hepatitis B Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially <br /> infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I <br /> have read and understand the health risks involved with Hepatitis B; however, I <br /> voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br /> transmission and have full knowledge of its effects on the human body. I understand <br /> that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br /> disease. <br /> SIGNATURE: DATE: <br /> PRINT NAME: Die" lbs ��'s <br /> ADDRESS: 4�—� - 64-iMp CA q ��3 <br /> 12-31 �rluvwb>r D( . CITY: STATEzip 0 <br /> W.\Da1a1EH-PROGRAMS&PROJECTS\BODYART\FORMSWORD DOG&KEPATITIS B DECLINATION STATEMENT.4 2313.6om <br />