Laserfiche WebLink
R I E 1EIVE <br /> 9 7 2012 <br /> ENVIP NM NTALHEAL114 <br /> Hepatitis B Vaccine Declination <br /> understand that, due to my occupational exposure to blood or Other Potentially Infectious <br /> Materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been <br /> given the opportunity to be vaccinated with hepatitis B vaccine at no charge/cost to myself. <br /> However, I decline hepatitis B vaccination at this time. I understand that by declining this <br /> vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I <br /> continue to have occupational exposure to blood or OPIM and I want to be vaccinated with the <br /> hepatitis B vaccine, I can receive the vaccination series at no charge to me. i <br /> Date Employee's printed name Employees signature <br /> Date Employer representative's printed name Employer representative's signature <br />