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�irn���e�nti IFle�ea�nti� 1� ����nLrne ��c�saaL$®n <br />I understand that due to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (I -MV) 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 acquhing 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, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne pathogens. Occupational Safety and Health Act. <br />I, TU C� N G YEIN/ have decided not to receiveinjections of <br />(flint Name) <br />0 <br />Date <br />I:�Policy and Legal CIIPU�ealtli Forms,Crim Bk, d Chck, drug screen, fingerprint for Smdents�iiealth <br />Fotvrs 2011.2012�I3ep R Vaccine Decline Fonu.doc <br />