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Facilit ID# <br />Program ID# <br />Hepatifiis B Declination Statemenfi <br />! 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 Be 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 />PRINT NAME: C � �1 �"""� �. \, G� �\ i ►� <br />W:1Dala1EH-('ROGRAMS R PROJECiS180DY ART\FORMS\WORD DOCSWEPATITIS 8 DECLINATION STATEMENT, 4 23 13.doa <br />DATE: <br />k.,r7 ZIP `5205 <br />