Laserfiche WebLink
�faa�tlenza Hep�fi�ba� 1� �/�cca�zc u�ec�all:aai©zz <br />I understand that due to my occupational exposure to blood or oder 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 Hepalilis B, a serious disease. If, in Elie <br />frlLLlre, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with Repatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Pedetal Regulations 1910.1030 Occupational <br />l.xposuic to Bloodborne Pathogens. Occupational Safety and Health Act. <br />rnrn <br />I, � 1 ,have decided not to receive injections of <br />(Print Name) <br />Date <br />1:\Policy and Legn] CHP\Health Porms,Crim Bkgrrl Chek, drug screen, fingerprint fm' Stndents\hIeallh <br />Pnrnis 201 1.2012\Hep R Vaccine Ueeliue Ponn.dor. <br />