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�iar�l�i 1Fie�tt�� �1ac�nzae �¢e�A�aCaQl� <br />I understand that due to my occupational exposure to Ulood or other potentially n fectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infections. <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, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Bxposure to B1oodUorne Pathogens. Occupational Safety and Health Act. <br />have decided not to receive injections of <br />I (Pnnt Name <br />I:iPolicy and Legal CHP�PIealtli Forms,Crim Bkgrd Cl�ci;, dnu screen, fingerpruitfor Smdents�IIealth <br />Forms 2011.2012Q3ep B Vaccine Declive Porm.doc <br />