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i <br /> Student Repadtis B Vaccine Deelillation <br /> I 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 it 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 T 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 Bloodborne Pathogens. Occupational Safety and Health Act. <br /> I, Mary Nguyen have decided not to receive injections of <br /> (Print Narne) <br /> i <br /> July 12, 2021 <br /> Date Signature <br /> I <br /> I <br /> 1APolicy and Legal CHMeallh Porms,Criur Ekgrd Click, drug screen,fingerprint for Students�Realth <br /> Forms 2011.2012\Hep R Vacchte Decline Fonn.doc { <br /> P, <br />