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Hcpalilis It Vaccination Declination Form <br /> Name. 1l (IF I LJ of v i , <br /> Deloarintcni _.� ��L) 0 1_� 4 � _ List d digils of StiN <br /> TIIE FOLLOWING NIUST BE SIGNED BY THE EMPLOYFF. IF HEPATITIS R <br /> VACCINATION IS REMSEU. <br /> I understand that due to lily occupalion:tl exposure to blood or other poterrlially infectious <br /> nrateriads I ntay be at risk of acquiring hepaiili% It vinrs ( I IBV ) inl'rcliun. I have lccn Disco the <br /> C opportunity to be vaccinated Willi hepalitis b vaccine, al no charge it) myself. I Inwcver. I decline <br /> hep, uitis [l vaccination et this time. I undersland that by defining Ihis vacciuc. 1 ill"' little to he at <br /> risk ofacquirin hep:dilis R , a serious disease. If in the I'uturc I continue ar beat risk ul' acyuiring <br /> hepatitis 13, a scriurrc disease. lid in the Inure I continue to have occupational exposure to blood or <br /> tVa polcntially inl2clinus materials and I Want to Ix: vaccinated Willi I Iepaiilis b vaccine, 1 can <br /> receive tc vaccination series at no clelrgc to mc. <br /> - 4� 3/ 23 � 2 � 2� <br /> - - - <br /> mild <br /> Signa c <br />