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el3-e ! epan LS 1 V-IcchTre ElcelH'n'tfoni <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I nilly be at risk of acquirkig or transmitting Hepatitis B virus (HBV)infectious. <br /> llowevei•,I decline ITepatitis 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 occopatlonal e..xposiire to blood or other potentially infectious <br /> materials and I want to be vaccinated with I�iepatids B vaccine,I i-nay 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,. have decided not to receive injections .f <br /> (Print Nan�e� <br /> Dile --- ---- i a azure <br /> 1,To'icy and Legal CHP1Health Forms,Crim T3Rgrd Chc c,drug screen,fingerprint for Studeiats'TXeaith <br /> Porms 20.1.1.20121IIep B Vacchic Decline Form.doc <br />