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I understand that due Co lily occupational exposure to blood or oilier potentially infecl,ious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (IIBV) iufeclious. <br />Tlowever, I decliuc 11cpatilis B vaccination at this Lime. I understand that by declining <br />this vaccine, I caartinue to be al risk ol'acquiring Ilepaiilis B, a serious disease. If, in [lie <br />fuLw•e, I continucto have occupational exposure to blood or other potentially infectious <br />materials and 1 want to be vaccinated with t-lepatitis B vaccine, I may do so. <br />Reference: ilppendix A, 29 Code oI' Federal Regulations J.91Q1O30 Occupational <br />Lxpo%stu'c totRlooclborne ratItOgGeus. Occupauonal Safety and Health Act. <br />I, Makir), V? c have decided not [o receive igjeetions of <br />(Print Name) <br />1:\Policy aad Legnl CHP\I-feallh T'orms;Crim 131:grr1 Click, drug screen, fingerpiinl for Smdeuts\Lknith <br />Fnnus 201 1:2912\Hep R Vaccine llecline Fonn.doc <br />