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�tan���$11eTw�finei5 ]� ��,v�nTru� Il��e�naL�aQn <br />I nuderstand that due to nny occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (IMV) infectious. <br />However, I decline Hepatitis.B vaccination at this time. I understand that by declining <br />this vaccine, I continue to be at risk of acqumng Hepatitis B, a serious disease. If, in the <br />uttue, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code oz Federal Revelations 1910.1030 Occupational <br />Exposure to Bloodhorne Pathogens. Occupational Safety and Health Act. <br />A have decided not to receive injections of <br />(Paint Name) <br />Signature <br />I:�Policy and Legal CHP�I3ealtl� Perms,Crim Bkb'd Chcl:, drug screen, fingerpruit for Smdentsll3ealfl� <br />Porms 2011 ?012�I-lep B Vaccitie Decline Form.doc <br />