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�ftaa�e�tt �����ni� � Cv���s>rIle it �cBa�n�tfl�n <br />I understand thaC due to my occupational exposure to Ulood or other potentially infectious <br />materials I may be at risk of acquiring or transmitting Hepatitis B virus (HBV) infectious. <br />However, I decline Hcpatitis 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 />fiiture, 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 />Exposlure to Bloodborne Pathogens. Occupational Safety and Health Act. <br />I, ✓14Z C 0 I 0 have decided not to receive injections of <br />(PiintName) <br />T:1Policy and Legal CHP�T3ealtli Forms,Crim Blcgrd Chcic, drug screen, fingerprint for SCudents�IIealdi <br />Farms 2011 ?012�I3epB VaccineDeclineFonu.doc <br />