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�$tr��ra4 �e��tu��� � C����fira� u���knla�tk�•�a <br />I understand thaC due to my occupational exposure to blood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <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, a 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 />Reference: Appendix A, 29 Code of Federal Regulations 1910.1030 Occupational <br />Exposure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, /U(�IU�?n l�POP2 have decided not to receiveMiecions of <br />(Paint Name) <br />Date <br />I:�Folicy and Legal CHP�Hea1tU Pornis,Criin Bkgrd Chcl:, ding screen, fingerpru�c for Studznts�flealth <br />Forms 2011.2012�I3ep R Vaccine DeclineI'onn.doc <br />