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Hepatitis B Vaccine Declination Form <br /> Facility Name: -JA-LjT <br /> Facility Address: --�QQ 6 )V1PMZ'f&,'- 1-4 <br /> 1 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. <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 /> &a4l vz� <br /> Employee's Name (Print) <br /> Employee's Signature <br /> I /141 <br /> Date <br />