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Students Repat tis B Vaccine Declination <br /> I understand that due to my occupational exposure to blood 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 /> 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 /> I, vy�Jl have decided not to receive injections of <br /> (Print Name) <br /> PC <br /> Date i a use <br /> IAPolicy and Legal CHP\Health Forms,Crim Bkgrd Chck,drug screen,fingerprint for SLudentsUlealth <br /> Forms 2011.2012\Hep B Vaccnie Decline Form.doc <br />