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I 1,11A 41 r! ITH M H 1 r "I J] 1"'M <br />Facility Name: <br />Facility Address: <br />I G GESS i c <br />.11 <br />I understand that due to my occupational exposure to blood or other potentially <br />infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. <br />I have been given the opportunity to be vaccinated with the hepatitis B vaccine, <br />at no charge to myself. <br />However, I decline hepatitis B vaccination at this time. I understand that by <br />declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious <br />disease. If, in the future, I continue to have occupational exposure to blood or <br />other potentially infectious materials, and I want to be vaccinated with hepatitis B <br />vaccine, I can receive the vaccination series at no charge to me. <br />M <br />�avgw <br />Employee's Name (Print) <br />C, <br />ployee's Signature <br />i -u4 -ice <br />101.1 M- <br />