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�tucient Hepatitis B Vaccine ]Declination <br />t understanrl that due to my occupational exposure u, blood or other potentially infectious <br />materials I may be at tisk of acquiring or transmitting Hepatitis B virus (14BV) infections. <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, it 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 Hepatitis B vaccine, I may do so. <br />Refet•ence: Appendix A, 29 Code of Tederai Regulations I910,103Q Occupational <br />Exposure to Hloodhorne pathogens. Occupational Safety and 1-icalth Act. <br />.t• <br />I, t h h I f V 064 have decided not to receive injections of <br />(Print Name) <br />l:V'olicy mtd Legal CHP\HcnUh Fnnns,Crim Rkgrd C:6ck, drug screca, fingerprint far Sludenls\ticalth <br />17rn•ms 2011.2012\lisp R Vaccine Ueeline Ponn.dw: <br />