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Agency <br />Date: <br />05/13/2019 <br />Professionars First Nam: <br />o rio <br />Professional's Last Name: <br />RG -M'1 re E tACAVIYA Q-27 <br />Professional's Email: <br />bon`( r4 `cre 40a@t ahmor.cclm <br />Professional's Mobile Phone: <br />(2U9) 922- 64 5C. <br />DECLINATION: <br />I am refusing the Hepatitis B Vaccine and hold harmless Tailored Healthcare Staffing, Health Carousel, LLC, and its partner organizations. 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. I have been given the opportunity to be vaccinated with Hepatitis B Vaccination. <br />I decline Hepatitis B Vaccination at this time. 1 understand that by declining the vaccine, I continue to be at risk for acquiring Hepatitis B, a serious disease. If in the future, while actively employed by Health Carousel and its <br />partner organizations, I continue to have occupational exposure to blood and other potentially infectious materials and want to be vaccinated with the Hepatitis B Vaccine, I can do so. <br />CONFIRMATION OF DECLINATION: <br />Monday, May 13, 2019 10:06 AM <br />11 <br />v <br />100%.- <br />S pt CP} 10:06 AM IM <br />