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Student Hepatitis B Vaccine Dedi atio r <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials Inlay be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br /> 13 <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 acquiring 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 with Hepatitis B vaccine, I may do so. <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br /> Exposur <br /> e to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> 1, e- t'et have decided not to receive injections of <br /> (Print Name) <br /> - - <br /> Date gnature <br /> IAPolicy and Legal CHP\Health Forms,Crim Bkgrd Click,drug screen,fingerprint for Students\1--lealth <br /> Forms 2011.2012\I1ep B Vaccine Decline Form.doc <br />