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I understand khat due to my 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 Ilepatitis 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 />fixture, 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 rederal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act, <br />I, P�AW1AVl Aye 0A r, have decided not to receive injections of <br />(Print Name) <br />I:�Policy and Legal CHP�IIeaiCU Porms,Crim Bkgrd Chcic, drag screen, fingerprint for SCudeufsUIealth <br />Dorms 2011.2012�I3ep B VacevieDecline Form.doc <br />