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Facility ID# <br /> Program ID# <br /> Hepatitis B Declination Statement <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. I <br /> have read and understand the health risks involved with Hepatitis B; however, I <br /> voluntarily decline Hepatitis B vaccination at this time. I fully understand the risk of its <br /> transmission and have full knowledge of its effects on the human body. I understand <br /> that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious <br /> disease. <br /> SIGNATURE: DATE: //I;K12 2, <br /> PRINT NAME: �G�� C5 o`2.Q\ <br /> ADDRESS: CITY: f ��j STATE r.4 ZIP qJ Gg C) <br /> 0 <br /> NOV 0 8 2022 <br /> 'ENVIRONMENTAL HEALTIJ <br /> PERMIT/SERVICES <br /> W.ZatMEH-PROGRAMS&PROJECTSIBODY ARTFORMS\WORD DOCS\HEPATITIS B DECLINATION STATEMENT,4 23 13.do" <br />