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I Undersland that due to my occtipallovial eXI)OSL1re to blood or other potentially infectious <br /> materials I may be it risk of acquiring or transmitting Hepatitis B virus(IJ-BV) infectious. <br /> However, I deciinc flepatilis B vaccination at this time. I understand that bN, declining <br /> this vaccine. I Continue in he at risk of acquiring Hepatitis B. a serious disease. If, in the <br /> I'Llutre. I continue to have Occupational exposure to blood or other potentially infectious <br /> materials and I want to b--vaccinated With l4el),lLi[jS 13 vaccine, I may do so. <br /> Reference: Appendix A. 29 Code of Federal Rcgulwions 1910.1030 Occupat loll al <br /> I-XI10.SLtrC to B100(lb0i'lle Path0geits. 0ectipational Safety and 11calth Act, <br /> c decidcd not.in receive I 11jecLiolls Of <br /> (Print Name) <br /> ,e'jyer <br /> 1APolicy and Legal C'HP\Hcahh Forms,Crim Bkgrd Click:drug,screen,Fin-o print for StUdClItSMIcalth <br /> Forms 2011.2012\Hel)8 Vaccine Decline Form.doc <br />