Laserfiche WebLink
Facilit 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 k owledge of its effects on the human body, I understand <br />that by declining this va Ei.e I continue to be at risk of acquiring Hepatitis B, a serious <br />disease. 7/ <br />SIGNATURE: DATE: �- e574 Q <br />>,:�1►r�naal� <br />ADDRESS: ,� Q CITY: STATE �� ZIP �j�j �� <br />W:\OaU\EN-PROGRgMS 8 PROJECT3INOOV gRTFORMSVWORD OOOSV1EPgTR15 B OECLINgTIGN STgTEMEM, 9 2313.dov <br />