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!.�1. <br /> epati"fis B VPA'CChri:e <br /> I understand that due to my occupational exposure to blood or other potentially infectims <br /> materials I may be at tisk of acquiixng or transmitting Hepatitis B vv-us (HBV)infectious. <br /> TTowevex, I decline ITepatitis.B vaccination at this tune. I understand that by declining <br /> this vaccine. I continue to be at risk of acquit-ing Hepatitis B; a serious disease. If, in the <br /> future, I continue to have occupational exposure to blood or other potentially infectious <br /> materials and I want to be vaccinated m6th Hepatitis B vaccine.Imay 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,.__ L90f L/ 6OY2& / �� have decided not to receive in?ections of <br /> (Print Name) <br /> 2&2/ _. <br /> Date Si�natur <br /> I;\Policy and Legal CHIAHe91th Forins,Crim TRg—d Chac,drag screen,;fingerprint for Stude its,11c:alth <br /> Morins 20J 1.201211-lep B Vaccirc Dechue Forni.dor. <br />