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1/9/2020 74DACB01-"BB-407C-BDDC-68FC76AA1OB3.J PG <br /> HEPATITIS B <br /> 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 <br /> However, I decline the Hepatitis B vaccination at this time i <br /> understand that by declining this vaccine. I continue to be at risk of <br /> acquiring Hepatitis B,a serious disease It in the future I continue to <br /> have occupational exposure to blood or other potently infectious <br /> materials and I want to be vaccinated with Hepatitis B vaccine. I can <br /> receive the vaccination series at no charge to me <br /> Artist Signature <br /> Date 4 it ��z0 <br />