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Hepatitis B Vaccine Declination Form <br />Eorsc-�-kz-v <br />FacilityName: <br />Facility Address: l 73 q 3 L� k <br />u C) <br />'CV1 l <br />I 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 />) �4 lu V� a1 � <br />Employ e's Name rint) <br />Em oyee's Signature <br />