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Hepatitis B Vaccination Declination Statement <br />(Fed OSHA 1910.1030 App A) <br />I understand that due to my occupational exposure to blood or other potentially infectious materials I <br />may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be <br />vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B <br />vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of <br />acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to <br />blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I <br />can receive the vaccination series at no charge to me. <br />Print . �� <br />22 <br />Date <br />