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a�tul€leuat �eiaa�il'is � �accl;rre k�ecliaa�tl®xa <br />I understand that due to my occupational exposure to Ulood or other potentially infections <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (1 -MV) infectious. <br />TTowever, I decline Hepatitis B vaccination at dus 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 />fuhu•e, 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 />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />P,xposure to Blooduorne Pathogens, Occupational Safety and Health Act, <br />I, AMY ACAYA have decided not to receive injections of <br />(Print Name) <br />I:\I'o]icy and Legal CHP\Health Forms,Crim Blgrd Click, drug screen, fingerprin[for Students\FTeal[h <br />Ponns 20I1.2012u-Iep 13 VaccL�e Decline Porm.doc <br />