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3ladeut Hepatitis H VRccitte Declination <br />I undeuatnnd that due to my occupatiotud exposure m blood or other potentially infections <br />materials i may be at risk of acquiring or transmitting Hepatitis H virus (1111V) infectious. <br />However, l decline llelratitis F3 vaccination nt this time, l understand thin by deelining <br />this vaccine, l continue to be at risk of acquiring Hepatitis 6, a serious disease. if, in the <br />forme, 1 continue to have occupational exposure to blood or other potentially infections <br />materials ami I want to be vaccinated with Ilepatitis B vaccine, I may do so. <br />Referrnee: Appendix A, 29 Crile of Fede gal Regulations 191U.I030 <br />Occupational <br />lixposm'e to Hloodbome pathogens. Occupational Safety and Health Act. <br />1, 1AI)yA \I have decided not to receive injections of <br />(Mat Name) <br />l:V'olicq wrd Legal CH14Fiealrh ponas,Cnm Ukgnl CItcA, dmg semen, fingerprint iw Swdentslltcaldr <br />perms 2011.2a121Hgr R Vncdrw Decline I�nnn.da: <br />