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1/6/2020 IMG_8209.jpeg <br /> HEPATITIS B <br /> DECLINATION FORM <br /> Appendix A to Section 1910.1030—HepatitiVaccine Declination <br /> I understand that due to my occupational exposure to blood or otfw <br /> potentially infectious a , t may be at risk of acquiring Hepatitis <br /> tfirus (I-IM infection. t have been given the opportunity to be <br /> vaccinated vaccine, charge to myself <br /> However, I decline the Hepatitis B vaccinationt this time. i <br /> understand ttfHepatitis , ic t k <br /> disease. of <br /> If i confinue <br /> have occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccirtated with Heptifis B vaccine, I can <br /> receive the vaccinationt no charge to me. <br /> Artist SigrL: <br /> �P <br /> Date <br /> https://mail.google.com/mail/u/0/?tab=rmO&ogbl#inbox?projector=1 1/1 <br />