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St�Ii�eirn� AL1-le�cl�neTS � ���cesi�ie �eeIl���ta�11n <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 (HBV) infectious. <br />However, I decline Hepatitis B vaccination at this time, 1 understand that by declining <br />this vaccine, 1 continue to be at risk of acquiring Hepatitis B, a serious disease, 1f, 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, Fraulien Ge�rn�, 6 , have decided not to receive injections of <br />(Punt Name) <br />i� � I S/coal <br />Date <br />Signatm'e <br />I:�Policy and Legal CHP�Iiealtl� Fonus,Crim Blcgt'd Chck, drug screen, fingerprint for SLudents�IIealll� <br />Forms 2011 ?012�Fi1ep B Vaccine Decline Porm.doc <br />