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atuacttt TrleIMI Is F3 Vacrittc I7eclilts�tit7n <br />1 understand that due to my oecupatiooal exposure to blood or other potentiarlly infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (IIBV) infectious. <br />However, I decline l lepatitis B vaccination at this lime. I understand that by declining <br />this vaccine, 1 continue to be at risk of acquiring Hepatitis li, a serious disease, If, in the <br />liuure, I continue to have occupatiorwl exposure to blood or other potentially infectious <br />malel'ials and I want to be vaccinated Willi Repattlls B vaccine, I may do so. <br />Reference: Appendix A, 29 Code of Federal Regulations 19 job 1030 occupational <br />Fxposure to I3loodhorne Pathogens. occupational Safety and Health Act, <br />have decided not to receive injections of <br />(Print N:unc) J <br />" �'� signawrc <br />, , -__, ,�unua,.,,uh F„rms.Critn l;krzrd Chck, dnlg screen, fingerprint for Studrnt�\I I <br />