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Student Hepatitis B Vace-i le <br />I understand that due to my occupational exposure to blood or other potentially infectious <br />materials Inlay be at risk of acquiring or transmitting Hepatitis B virus (HBI) infectious. <br />However, I decline Hepatitis.B vaccination at this tune. 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, 1 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 />Rx iosure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I; _. , have decided not to receive infections of <br />(Prim Mime) <br />D2L <br />Signature <br />Q%ft • <br />1APolicy and Legal CHP\Heall.h Forins,Crhn Bkgrd Click, drug screen, fingerprint for Students\ 1calth <br />Forms 2011.2012\Hep B Vaccuie Decline Forcn.doc <br />