Laserfiche WebLink
Student 11111'epatifis 18', Varmllline Decelf,,nieat T-'0,HL <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 vials (HBV) infectious. <br /> However, I decline Hepatitis B vaccination at this time. 1 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, 1 continue to have occupational exposure to blood or other potentially infectious <br /> materials and 1 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 /> Exposlue to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> 1, _ gvina , have decided not to receive injections of <br /> (Print Name) <br /> .mate � Si lature <br /> 1:APolicy and Legal CHP\Health Porms,Crirn Bkgrd Clack, drug screen,fingerprint for Students\Health <br /> Forms 20.11.2012TIep B Vaccine Decline Forsn.doc <br />