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Student Hepatitis B Vaccine Declination <br />I understand that due to my occupational. exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />However, I decline Hepatitis B vaccination at this time. I understand that by declining <br />this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. if, in the <br />future, T 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 of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, AU'-;M� L K V have decided not to receive injections of <br />(Print Name) <br />2® <br />Date Signature <br />IAPolicy and Legal CHP\HeaIih Forms,Crim Bkgrd Chch, drug screen, fingerprint for Students\Health <br />Forms 2011.2012\1-lep B Vaccine Decline Form.doc <br />