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�t9��lezti Flepa�e�s 1� �accbr►e Jl�ecliliati®Ya <br />I understand that tine to my occupational exposure to blond or other• potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (13BV) infections. <br />However, I decline Hepatitis B vaccination at this time. I understand that by declining <br />his vaccine, I_continue to be at tisk of acquiring Hepatitis B; a serious disease. If, in the <br />future, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be. vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code ofPederal Regulations 1910.10311 Ot;aupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and health Act. <br />I . FP.an Ch Pl Y O have decided not to receive injections of <br />(Print MM6) <br />I:\Policy.and Legal CHP\Heallh T'onns,Ciim [31:grd Click, drug screen, fingerpeitat%r S[udeats\T•Tealth <br />1?orms2011.2012\Hep S. Vaccute Decline )�oi�m.doc <br />