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I understand that due to riiy occupational exposure to Ulood 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.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, 1 may do so. <br />Reference: Appendix A, 29 Cade of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, V .P t- ,have decided not to receive injections of <br />lint Nam ) <br />Date <br />Signature <br />I:�Policy and Legal CHPlI3ealtki Porms,Crim Bkgid CUck, drug screen, fingerprint for Students�IIealth <br />Forms 2011 ?017_,I-Iep B Vaccine Decline Poxan.doc <br />