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tax€t� t Lig c�tne�� 1� Vacdxte Declination <br /> 1 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 (HB V) 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 /> ftAUML, 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 andHealtb Act. <br /> I, 4 } � � <br /> � Mf I � U have decided not to receive injections of <br /> (Print Name) <br /> 2Z Z <br /> Date b ature <br /> IAPolicy and Legal CHP\Healdi Fornas,Crim Bkgrd Chck, drag screen, fingerprint for Shidents\IIealth <br /> Forms 2011 .20129VIep B Vaccine Decline Form.doc <br />