Laserfiche WebLink
HEPATITIS B DECLINATION FORM <br /> Appendix A to Section 1910.1030— Hepatitis B Vaccine Declination <br /> I understand that due to my occupational exposure to blood or other <br /> potentially infectious materials, I may be at risk of acquiring Hepatitis <br /> B Virus (I-IBV) infection. I have been given the opportunity to be <br /> vaccinated with Hepatitis B vaccine, at no charge to myself. However, <br /> I decline the Hepatitis B vaccination at this time. I understand that by <br /> declining this vaccine, I continue to be at risk of acquiring Hepatitis B, <br /> a serious disease. If in the future I continue to have occupational <br /> exposure to blood or other potentially infectious materials and I want <br /> to be vaccinated with Hepatitis B vaccine, I can receive the vaccination <br /> series at no charge to me. <br /> Artist Signature <br /> Date <br />