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r <br /> Body Art Facility Name: <br /> Body Art Facility Address: <br /> City A Zip Code <br /> i <br /> Hepatitis B Vaccination Declination Form <br /> Declination Statement* <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the <br /> opportunity to be vaccinated with Hepatitis B vaccine, at no charge to me; however, I decline <br /> Hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at <br /> risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational <br /> exposure to blood or other potentially infectious materials and I want to be vaccinated with <br /> Hepatitis B vaccine, I can receive the vaccination series at no charge to me. <br /> Signature: Date: <br /> Name: (Print) <br /> *Taken from:Bloodborne Pathogens and Acute Care Facilities.OSHA Publication 312$,(1992). <br />