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HEPATITIS B <br /> DECLINATION FORM <br /> Appendix A to Section 1 10,10uvi—Hepatitis 8 Vaccine DecOnation <br /> l understand that due to a y occupational exposure to blood or other <br /> potentially infectious materials,I may be at risk sof acquidna Hepatitis <br /> Virus (1„I t#) infection. i have been given the opportunity to be <br /> vaccinated with hepatitis B vaccine. at no charge to r yself. <br /> However, I ch"ne the Hepatitis 8 vaccination at this time. I <br /> Understand that by declining this vaccine, I continue to be at risk of <br /> acquiring Hepatitis S.a serious disease. If in the€ t re i continue to <br /> have coupatlonai exposure to blood or othef potentially infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine,l can <br /> receive the vaccination series a char a to rage. <br /> Artist Signalur .. <br /> I Date _ P <br />