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1/9/2020, 74DACB0I-F7BB-407C-8DDC-68FC76AA10B3.JPG <br /> HEPATITIS B <br /> DECLINATION FORM <br /> Appendix A to Section 1910 1030-Hepatitis 13 Vaccine Ded,inabon <br /> I understand that due to my occupational exposure to blood ot other <br /> potentially infectious materials, I may be at risk of acquiring Hepatitis <br /> B Virus (14i V) infection I have been given tho opportunity to be <br /> vacrinated with Hepatitis B vaccine. at no charge to myself <br /> However, I declir* the Hepatitis B vaccination at thts time I <br /> understand that by declining this vaccine, I continue to be at nsk of <br /> acqutring Hepatitis 8, a serious disease It in the future I continue to <br /> have occupational exposure to blood or other potentially int echous <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I can <br /> receive the vaccination series at no charge to rne, <br /> Artist S#gnature <br /> to lhol2o <br />