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Facility Name. 16 <br /> Facility Address: 'b D (A) �, -VV Lo6tL A 1 2 <br /> 1 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. <br /> I have been given the opportunity to be vaccinated with the hepatitis B vaccine, <br /> at no charge to myself. <br /> However, I decline hepatitis B vaccination at this time. I understandthat by <br /> declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious <br /> disease. If, in the future, I continue to have occupational exposure to blood or <br /> other potentially infectious materials, and l want to be vaccinated with hepatitis B' <br /> vaccine, I can receive the vaccination series at no charge to me. <br /> Employee's-Name (Print) <br /> Employee's Signature <br /> Date <br />