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�YIY�ennY ��epaYnYis � Vacciaae �eclitaatiola <br />I understand that due to my occupational exposure to Ulood 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 I-Iepatitis 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 1 want to be vaccinated with Hepatitis B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulatigns 191U.1U30 Occupational <br />I xposure to B1oodoorne Pathogens, Occupational Safety and Health Act. <br />I, , have deci.decl not to receive injections of <br />L•�Policy and Legal CHP\Health Aortns,Crim 13kgrd Chck, drug screen, fingerprintfm• StudentsllIcalth <br />I+orins2011.2012U-IepRVaccuraDeelineFonn�oc <br />