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Hepatitis B Vaccination Declination Form <br />Name. L cI Mc>✓rkcv�e� Ta�� <br />Department �►1VILMIVIAI IWAI 1I Ifn Last 4 digits of SS# Da <br />THE FOLLOWING MUST BE SIGNED BY TAE EMPLOYEE IF HEPATITIS B <br />VACCINATION IS REFUSED. <br />I understand that due to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the <br />opportunity to be vaccinated with hepatitis b vaccine, at no charge to myself. However, I decline <br />hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at <br />risk of acquiring hepatitis B, a serious disease. If in the future I continue to be at risk of acquiring <br />hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or <br />other potentially infectious materials and I want to be vaccinated with Hepatitis b vaccine, I can <br />receive the vaccination series at no charge to me. <br />Date <br />ltev it/00 <br />