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AppendixHEPATITIS B <br /> DECLINATION FORM <br /> A to Section t 1 ,t —}hepatitis B Vaccine ii <br /> I understand that due to my occupational exposure to blood or other <br /> potentially infectious materials, t may be at risk of acquiring Hepatitis <br /> Virus (1-03V) infection. t have been giventhe opportunity to be <br /> vaccinated vAth Hepatitis B vaccine. at no charge to myself. <br /> However, decline the Hepatitist` t this time. <br /> unclarstand that by declining vaccine, f continue to be at risk of <br /> acquiring H%iditis B, a serious disease. K in the Mire t continue to <br /> have occupational exposure to blood or other potentiallyinfectious <br /> mitterials t t t vaccinatedHepatitisvaccine,I can <br /> receive the vaccination series at no chmW to me. <br /> Artist Signature <br /> Ime2 <br />