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�ttsdclut JEi!.ei�atitis B Vaccine �t:clination <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 Hepalitis B vims (HBV) infectious. <br />Flowever, I decline Hepatitis B vaccination at this time. I understand that by declining <br />this vaccine, I continue to be at risk of acquiring I lepatilis 13, 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 II vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal 12cgulations IIIQIQ�U Occupational <br />l?spusore to Rlondhorne Pathogens, Occupational Safety and Ilcalth Act, <br />Din In <br />(Krim Name) <br />3/1/21 <br />pate <br />Bernal <br />have decided not to receive injections of <br />1:U'olicy and Legal CHP\}lealJi Fonns,Crim i3kgrJ Chck, drug screen, Gngciprint fm StudentstFicalth <br />Roans 2011.2012\Hep R Vaccu�c [lection ronn.Joc <br />