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Bey y <br /> z <br /> jd /�.��� <br /> €{.J4l:U <br /> 7. 11�rt N,Kktlf tri 5nu� >. <br /> Nx <br /> Health Care Professional-Hrpat# <br /> Hepatitis B DeclinationStatement <br /> WNP <br /> T>te following statement ofdeclination of hepatitis B v anon <br /> chases fi to wept the vaccine.The statement can signed yithe c <br /> appropriate training regarding hepatitis ,hepaUtt l3 tion.the efficacy. �P <br /> administration,and benefits of vaccination,and the and vaccination arc <br /> charge to the employee.The statemcnt is not a ht a';�1° uvees can request and <br /> vaccination at a later date if they remain occupational Isk for hepatitis B <br /> Declination Statement <br /> I understand that clUte t#t ood or other potentially <br /> infectious materim J, a B virus(HBV)tntz cttcrtt <br /> have been given tite hepatitis B vaccine,at no <br /> charge to mea istime. I un <br /> that by declining" g hepatitis" <br /> serious disease.If.In Ow exposure to bl <br /> or other potentially" � cii�ted with hepa' <br /> B vaccine,I can receiWt$ <br /> Etnplo Si tore: c, <br /> 1 <br /> Taken from:&loodborne f uthls, c r.�etticl Act Ili 2) <br /> Vii <br /> � . • <br /> n <br />