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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:1 -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. If in the future I continue to <br /> have occupational exposure to blood or other potentially 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 <br />