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,Sit Wert Hepatifis B Vaceirie Deeiinatrion <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 (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, 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 /> , have decided not to receive injections of <br /> I (Pint Name <br /> F <br /> Date Sig, tur <br /> I:u'olicy and Legal CHP\Healtb Forms,Crim Bkgrd Chck,dnu screen,fingerprint for SLvdents\Ilealth <br /> Forms 2011.2012Q3ep B Vaccine Decline Form.doc <br />