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1 understand that due to my occupational exposure to Ulood or other potentially hnfectious <br />materials I may be at risk of acquiring or transnutting Hepatitis B virus (HBV) infectious. <br />However, 1 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 />funs e, 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. Occ�national Safety and Health Act. <br />I, .-YOOV7 ap� rc2 , have decided not to receive injections of <br />(Print Name) <br />I:�Policy uid Legal CHP1Fiealfli Porms,Crim Bkgrd Chcic, drag screen, fingzrprinC for StudzntsiI3ealUi <br />Forms 2011 ?012�I3ep B Vaccine Decline Ponn.doc <br />