Laserfiche WebLink
Ji:taden '-wepa%His 1P3 Vaechle DecUnazion <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. 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 infections <br />Materials and I want to be vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of rederal Regulations 1910.1030 Occupational <br />Ex )osure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />1 4I CanD , have decided not to receive injections of <br />(Print <br />Date <br />[Mame) <br />Sigiiahu•e <br />t:\Policy and Legal CHP\Health Forms,Crim Bkgrd Chcl., drug screen, .fingerprint for Stndents\[-Iealth <br />Forms 2011.2Q12\Hep B Vaccu�c Decline Fonn.doc <br />