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Sh-k $ent Hepatitis lB Vaccine Declination <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, 1 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 /> I, SA�L © r„ , have decided not to receive injections of <br /> (Print Name) <br /> � r2 <br /> Date It <br /> I:1Policy and Legal CHPUllealth Forms,Crim Bkgrd Chck, drag screen, fingerprint for S m dentsV-1calth <br /> Forms 2011 2012ii3ep B Vaccine Decline Fonn.doc <br />