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I understand that due to my occupational exposure to blood or other potentially infectious <br />materials I may beat risk of acquiring or transmitting Hepatitis B virus (EBV) 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 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 />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />have decided not to receive injections of <br />(Print Name) <br />Date <br />I:�Policy and Legal CHP�Iiealdi Forms,Crim BIcgrd Chcic, drug screen, fingerprint for Students�I3ealfli <br />Forms 2011 ?0121iiep R Vaccine Decline Fonn.doc <br />