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Student llepa1r,1ls } Vacesme -10oer t,_a* 0 <br /> I understand that due to my occupational exposure to blood or otbeer potentially infectious <br /> materials 1 may be at risk of acquhing or transmitthtg l-lepatitis B virus (I-MV) infectious . <br /> However, T decline Hepatitis,B vaccination at this time. I Understand that by declining <br /> this vaccine. I continue to be at risk of acquiring Hepatitis B ; a serious disease. If, in the <br /> future. I coutirme to have occupational exposure to blood or other potentially infections <br /> materials and I want to be vaccinated with Hepatitis B vaccine, I may do so. <br /> Reference; Appendix A, 29 Code of Federal Regulations 1910. 1030 Occupational <br /> Exposure to Bloodborne Pathogens. Occupational Safety and health Act. <br /> I: 4 � '�'N(� A ar, have decided not to receive injections of <br /> (Print Name) <br /> 1 <br /> D to Signature <br /> IlrPoliey and Legal CHMeal Ili Forms,Com Bl.grd Click; dru@screen, fiogergrintfor Studeots`Sieal[It <br /> Forms 20.1 J 20MHep B Vaccine Dec] ine Fozm.dod <br />