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tCr_diei.j:�._I1G.-Q,i171'.0;1�'{? <br /> I understand that due to my occupational exposure to blood or other potentially=infectIMIS <br /> materials I may be at risk of acelu.iriiig or transnlifting Hepatitis B viru.S (HBV)infectious, <br /> However,I decline ITepatitis B vaccinatiOB at t his time. I understand that by decli,iing <br /> this vaccine. I continue to be at ride of accluia-ing Hepatitis B. a serious disease. H. in the <br /> future, I continue to hfive,occupational exposure to blood or other pote ltially infeetious <br /> materials and I want to be vaccinated with Hepatitis B vaccinc,1-may do so. <br /> Refererim Appendix A, 9-9 Code of Federal Regulations 1.910.1030 Occupational <br /> Exposu"A to Bloodborne Padhogens. Occupational Safety and Wealth Flet. <br /> Up f <br /> have,decided not to receive injections of <br /> (Print Name) <br /> Date <br /> I;�'olicy and Legal CH'P\Health>io3.3us,Crim Bkgrd Chck,drug screen,fingerprint,for StudentAlic,11th <br /> Pones 20.11.2012\IIep.B VacciJ7C Dechue ronn.doc <br />