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Sftaz�elnt: gi¢p�atnc�� j� V���A9a� �Q�Aet��fii61�9 <br />I understand thaC 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 (I -IBV) 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 />fiiture, I cont nue 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 />Exposure to Blooduorne Pat/hoogens, Occupational Safety and Health Act. <br />I, S Al'I o Y I have decided not to reccive injections of <br />(Print Name) <br />I:�Policy and Legal CHP1Healtlt Porms,Crim Blcgrd Chc1c, drag screeq fingerprint for Students�TIealth <br />Pones 2011.2�I2U3ep B Vaccine Decline Form.doc <br />