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j <br />i <br />Hepatitis B Vaccine Declination Form <br />. . . . . . . . . . . . . <br />G <br />1° <br />r. <br />x <br />Facility Name, i 1G ) <br />G Gi t y"Ci i A-C(V Cf) 6f <br />Facility Address. Id�1 <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 (H'B'O 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 />Employee's Name (Print) <br />'Employee's ign ure <br />