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Au,g, 29, 2013 11:21AM I WORKNET No, 5384 P. 3 <br />F <br />Facility Name: <br />Facility Address. <br />3310 A)- 'RAQW <br />Alda' 50"f <br />e <br />I understand thatdUe to my occupational eipo6ure to blood or other potentiWly <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 S, a serious <br />disease. If, in the future, I continue to have occupption6l exposure fib blood or <br />other potentia'(Iy infectious material's, and I want to be vaccinated With hepatitis Br <br />vaccine, I can receive the vaccination, series at no charge to irne., <br />Emplbybe's Name (Print) <br />Date <br />Received Time Aub -29- 2013 11:25AM No,0788 <br />