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Student I lepaltitis B Vaccine DechimEion <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 11cpatilis 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, I may do so . <br /> Reference: Appendix A, 29 Code of Federal Regulations 1910. 1030 Occupational <br /> Fxposurc to Bloodborne Pathogens. Occupational Safety and Health Act. <br /> I, , C V\O e Ae \r'sM(g V,\L , have decided not to receive injections of <br /> (Print Name) <br /> DaL l Siguature s <br /> 1:\Policy and Legal CHP\Health Fm1i s,Critn Bkgrd Click, drug screen, fingerprint for Students\Hcahh <br /> Forms 2011 ,2012\I-Iep B Vaccine Decline Form,doe. <br />