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��t��rl�=elz^ifr5l 'Ila��4r:�1J'erl��t�fydr_ <br />I understand tUat due to my Dccupatiortial exposure tD U16od.or uther potentially infec(ious <br />materials I may be at risk of acquiring or transmitting Hepatitis B viral (I -IBV) infectious. <br />Tlowever, T decline I-Tepatitis.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 T want to be vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulafions 191G.1030 Occupational <br />Bxposurt: to Aloodborinee Pathogens, Occupational Safety and IJoaltb Act. <br />I; 11r/GMAVL(� have decided not to receive injections of <br />(Print Name) <br />Date Sienature <br />I:�FoLcy and Legtd CHP\Health Porms,Crim Blrgrd Cock; drug screen, ilugerPrintfor Studeuts}STcallh <br />Foy ms 201 1 �012\Hep R Vaceinc 7Jecl ine Fonn.doa <br />