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I understand thaC dne,to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious, <br />However, I decline Hepatitis,13 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, 1 may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Exposunre to Bloodborne Pathogens. Occupational Safety and Health Act. <br />q <br />I /�'! (Ch a I CU(rsoo have decided not to receive injections of <br />(PLv)t Name) <br />2Z <br />Dare <br />Signature <br />I:�Policy and Legal CHP�IIea1CU Porms,Crim Bk,�d Click, drag screen, fingerpru�C for Sfudents�Iieal[h <br />Forms 20113012�I3ep B Vaccine Decline Form.doc <br />�f <br />i <br />2Z <br />Dare <br />Signature <br />I:�Policy and Legal CHP�IIea1CU Porms,Crim Bk,�d Click, drag screen, fingerpru�C for Sfudents�Iieal[h <br />Forms 20113012�I3ep B Vaccine Decline Form.doc <br />