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Hrp:flilic It Vuccinrlinn I1cclinuUon Form <br />Name. <br />Deparintcnl .I ll 1 I_� I _ 1 usl d Ji�ils of titiN I'�(v <br />'fill: FOLL(11VING MUST 13E SIGNED f3Y TNF. Ed11'WYEF. IF HEPATITIS D <br />1'ACCINATION IS REMSED. <br />I understand that clue w my orcupatiunal cxln+sunr to hhxxl or other pntemi:+Ily inlcctious <br />I and rsAl I d m l at risk of acquiring hrpaiilis 13 vin++(IIBV) infection. I have been ei�cn the <br />opportunity to be vaccinated will, hepalilis b vaccine, al no charge to myself. 1lmvcvcr. I decline <br />hcp,uitis D vaccinalinu an chti <br />is me. I understand Ihat by declining this vaccine. I continue to he at <br />risk ol'acyuirittg hepalitis R. a serious disease. If in the future I continue Io be at risk of acquiring <br />riskIt o tis 13, i serious disease. I I' in the liuure I continue to have occupational exposure to hlood or <br />other po(cnti scllY infcclious maicrials and I want to be vaccinated will, I lepalkis b viecine, 1 can <br />receive tc vaccination series at no charge to lite. <br />Signa c <br />