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�ta�a;Aatr Ji�e��a�;iis l� V�c�:iate b�eelilta3i®t� <br />I understand Chat due to my occupational exposure to blood or other po[entially 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 />future, I continue to have occupational exposure to blood or other potentially infectious <br />materials and I want to be vaccinated with I3epatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Cade of Pedered Regttla[ions 1910.1030 Ocettpational <br />l xposurc to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I Mary Nguyen have decided not to receive injections of <br />(Print Narne) <br />July 12, 2021 <br />Date <br />Sigttatn•e <br />I:\Pglicy and Legal CHl'\Health Porms,Crim El:grrl Chck, drug screen, fingerprint for Students�d-IcalLh <br />forms 2011.2012\Hep R Vaccute Decline Fonn.doc <br />